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					                                    Editors-in-Chief

                                             Michel Hersen
                                 Pacific University, Forest Grove, Oregon

Michel Hersen, Ph.D., ABPP, is Professor and Dean, School of Professional Psychology, Pacific
University, Forest Grove, Oregon. Dr. Hersen is a graduate of State University of New York at Buffalo,
and completed his post-doctoral training at the West Haven VA (Yale University School of Medicine
Program).
   Dr. Hersen is past president of the Association for Advancement of Behavior Therapy. He has co-
authored and co-edited 133 books, and has published 223 scientific journal articles. Dr. Hersen is also co-
editor of several psychological journals, including Behavior Modification, Aggression and Violent Behavior:
A Review Journal, Clinical Psychology Review, Journal of Anxiety Disorders, Journal of Family Violence,
Journal of Clinical Geropsychology, and Journal of Developmental and Physical Disabilities. He is editor-in-
chief of a new journal entitled Clinical Case Studies, which is devoted to description of clients and patients
treated with psychotherapy. He is co-editor of the recently published 11-volume work entitled:
Comprehensive Clinical Psychology.
   Dr. Hersen has been the recipient of numerous grants from the National Institute of Mental Health, the
Department of Education, the National Institute of Disabilities and Rehabilitation Research, and the
March of Dimes Birth Defects Foundation. He is a diplomate of the American Board of Professional
Psychology, Fellow of the American Psychological Association, Distinguished Practitioner and Member of
the National Academy of Practice in Psychology, and recipient of the Distinguished Career Achievement
Award in 1996 from the American Board of Medical Psychotherapists and Psychodiagnosticians. He has
had full-time and part-time private practices.



                                             William Sledge
                                 Yale University, New Haven, Connecticut

William H. Sledge, M.D., is Professor of Psychiatry at Yale University School of Medicine, and is the
Medical Director of the Psychiatric Services at Yale-New Haven Hospital. Dr. Sledge is a graduate of
Baylor College of Medicine and the Western New England Institute for Psychoanalysis. He completed his
residency training in psychiatry at Yale University, Department of Psychiatry.
  Dr. Sledge has been a faculty member at Yale University School of Medicine for 25 years. He has
written about psychotherapy and psychoanalysis and is a mental health services and health services
investigator. In addition, he provides psychiatric consultation to the aviation industry and investigates the
neurobiological basis of the thought disorder of schizophrenia.
  Dr. Sledge has had a long, distinguished career as an educator, and has functioned as an administrator
of a variety of medical educational programs at Yale. In addition to his medical duties, he has been Master
of one of the Yale undergraduate residential colleges, Calhoun College, for seven years, and is the chair of
the Council of Masters.
  Dr. Sledge has been active in the American Psychoanalytic Association and the American Psychiatric
Association, primarily in the areas addressing education and psychotherapy. He is former chair of the
American Psychiatric Association Committee on the Practice of Psychotherapy and a member of the
Commission on the Practice of Psychotherapy by Psychiatrists. He is a member of the Group for
Advancement of Psychiatry Committee on Therapy.
                                  Associate Editors
                                             Alan M. Gross
                              University of Mississippi, Oxford, Mississippi

Alan M. Gross, Ph.D., is Professor of Psychology and Director of Clinical Training at the University of
Mississippi. He is the former editor of the Behavior Therapist journal, and recently served as associate
editor for the Journal of Clinical Child Psychology. He currently serves on the editorial boards of several
scientific journals, including Behavior Therapy, Journal of Clinical Child and Adolescent Psychology,
Behavior Modification, Journal of Family Violence, and Aggression and Violent Behavior.
Professor Gross has published numerous articles and book chapters in the area of self-management,
behavior problems in children, and sexual aggression.


                                               Jerald Kay
                       Wright State University School of Medicine, Dayton, Ohio

Jerald Kay, M.D., is Professor and Chair in the Department of Psychiatry at Wright State University
School of Medicine, Dayton, Ohio. He is a Fellow of the American College of Psychiatrists and of the
American Psychiatric Association (APA). Currently he is the chair of the APA Commission on the
Practice of Psychotherapy by Psychiatrists. He is the founding editor of the Journal of Psychotherapy
Practice and Research and associate editor of the American Journal of Psychotherapy.
Dr. Kay is the editor of 8 books and has published extensively on the topics of medical and psychiatric
education, medical ethics, child psychiatry, psychoanalysis, psychotherapy, and psychosocial aspects of
AIDS and of cardiac transplantation. He was designated as a 1994 Exemplary Psychiatrist by the National
Alliance for the Mentally Ill and is the recipient of the 2001 APA-NIMH Seymore Vestermark Award for
contributions to psychiatric education.


                                           Bruce Rounsaville
                     Yale University School of Medicine, New Haven, Connecticut
                                                and
                       U.S. Veterans Administration, West Haven, Connecticut

Bruce Rounsaville, M.D., is Professor of Psychiatry at the Yale University School of Medicine and director
of the U.S. Veterans Administration New England Mental Illness Research Education and Clinical Center.
Since he joined the Yale faculty in 1977, Dr. Rounsaville has focused his clinical research career on the
diagnosis and treatment of patients with alcohol and drug dependence. Using modern methods for
psychiatric diagnosis, Dr. Rounsaville was among the first to call attention to the high rates of dual
diagnosis in drug abusers. As a member of the Work Group to Revise DSM-III, Dr. Rounsaville was a
leader in adopting the drug dependence syndrome concept into the DSM-III-R and DSM-IV Substance
Use Disorders criteria.
Dr. Rounsaville has been a strong advocate for adopting psychotherapies shown to be effective in rigorous
clinical trials. Dr. Rounsaville has also played a key role in clinical trials on the efficacy of a number of
important treatments, including outpatient clonidine/naltrexone for opioid detoxification, naltrexone for
treatment of alcohol dependence, cognitive–behavioral treatment for cocaine dependence, and disulfiram
treatment for alcoholic cocaine abusers. He has contributed extensively to the psychiatric treatment
research literature in over 200 journal articles and 4 books.


                                           Warren W. Tryon
                                 Fordham University, Bronx, New York

Warren W. Tryon, Ph.D., ABPP, is Professor of Psychology and Director of Clinical Training at Ford-ham
University, Bronx, New York. He is a fellow of Division 12 (Clinical Psychology) of the American
Psychological Association, a fellow of the American Association of Applied and Preventive Psychology,
and a founder of the Assembly of Behavior Analysis and Therapy. He is a diplomate in Clinical
Psychology— American Board of Professional Psychology (ABPP). He is listed in the National Register of
Health Service Providers in Psychology and is a licensed psychologist in New York State.
Dr. Tryon has published over 130 articles, has authored 1 book, and edited 2 others. He has presented over
115 papers at professional meetings. Dr. Tryon is on the editorial board of Behavior Modification and has
served as reviewer for for over 30 journals and publishers. Seventy doctoral students have completed their
dissertations under his direction.
                             EDITORIAL ADVISORY BOARD
  DAVID H. BARLOW                     W. KIM HALFORD               LESTER LUBORSKY
    Boston University,                Griffith University,      University of Pennsylvania,
  Boston, Massachusetts               Nathan, Australia         Philadelphia, Pennsylvania

  BERNARD BEITMAN                   SANDRA LEE HARRIS            WILLIAM L. MARSHALL
   Columbia, Missouri                 Rutgers University,           Queens University,
                                    Piscataway, New Jersey          Kingston, Canada

    LARRY BEUTLER                                                 MALKAH NOTMAN
 University of California,            MARDI HOROWITZ              Cambridge Hospital,
      Santa Barbara,               Langley Porter Psychiatric   Cambridge, Massachusetts
 Santa Barbara, California                 Institute,
                                    San Francisco, California
                                                                  JOHN SCHOWALTER
 NICHOLAS CUMMINGS                                                   Yale University,
   Scottsdale, Arizona               HORST KAECHELE              New Haven, Connecticut
                                       Ulm, Germany
PAUL M. G. EMMELKAMP                                            BONNIE R. STRICKLAND
 University of Amsterdam,             OTTO KERNBERG             University of Massachusetts,
Amsterdam, The Netherlands          Cornell Medical Center,               Amherst,
                                    White Plains, New York       Amherst, Massachusetts

      EDNA B. FOA                                                  MYRNA WEISSMAN
  Allegheny University                  SUSAN LAZAR                Columbia University,
Philadelphia, Pennsylvania            Bethesda, Maryland           New York, New York
                                                   Preface


   When we began this project, it would have been be-                in psychotherapy. Topics were selected in order to give
yond our most radical beliefs to think that we would be              broad coverage of the field (albeit not exhaustive) so as
seeing a nation fraught with intense worry, anxiety, acute           to encompass the most contemporary schools and ap-
stress disorder, post-traumatic stress disorder, grief, and          proaches that have clearly defined techniques, some
depression less than three years later. So now, as we put            form of systematic study, and measurement of out-
our finishing touches on this work, and following the                 comes. Eclectic and integrative approaches have also
terrorist incursions, we regrettably have been forced to             been considered. Additional topics that transcend all
see the graphic proof of the inherent value of psy-                  schools, such as the impact of culture and the impor-
chotherapy. The critical contributions and the value of              tance of the therapeutic relationship, have also been in-
the psychotherapeutic arts have never been clearer to us             cluded as well as discussion of the treatment for some
than in the aftermath of the terrorist strikes. We say this          specific disorders.
with much humility, in that we would have preferred to                  Psychotherapy is an extremely complicated process
continue to talk about the sometimes small theoretical               that is difficult to fully capture even in a work of large
differences in various psychotherapeutic applications, in            scope, such as this encyclopedia. The interplay be-
what now seem to be needless polemics between such                   tween scientific confirmation of particular strategies
psychotherapeutic camps. Nonetheless, the original in-               and the actual implementation of a given therapeutic
tent (which continues today in spite of world events)                technique is not always isomorphic. Also, how theory
was to present a compilation of both the science and art             drives practice and ultimately the empirical confirma-
of psychotherapy.                                                    tion of such practice, is not always clear cut. Moreover,
   Psychotherapy has been a vital treatment in health                how cultural, financial, legislative, and forsensic issues
care since development of the great innovative and tech-             act in confluence further complicate the intricacies of
nical approaches embodied by psychoanalysis and be-                  what we refer to as psychotherapy. However, it is these
haviorism at the beginning of the 20th century. In the               very intricacies and complexities which make psy-
course of its development, many questions have been                  chotherapy such an interesting field to examine. In
raised about this treatment: What is psychotherapy?                  many ways, this work may raise more questions than it
How does it work? Which forms are cost effective? Who                does provide answers, and that, perhaps, is the way it
can do it? How does it fit into a comprehensive approach              should be.
to health care? What is its scientific basis? How does the-              The Encyclopedia of Psychotherapy is designed to
ory drive treatment? What is the role of complementary               serve the needs of a multi-faceted audience. As a refer-
treatments such as pharmacotherapy in combination                    ence work, we see it being used by students and pro-
with psychotherapy?                                                  fessionals from counseling and clinical psychology,
   The Encyclopedia of Psychotherapy strives to answer               psychiatry, psychiatric nursing, and social work. Cer-
the aforementioned questions. It is a comprehensive                  tainly, other disciplines will make reference to it as
reference to extant knowledge in the field and written                well. But the encyclopedia will also be of use to inter-
in clear expository language so that it will be of value to          ested lay individuals seeking information about this
professional and lay persons alike. Within its pages,                burgeoning field. Topics are arranged alphabetically.
this encyclopedia addresses over 200 topics by experts               As appropriate, a good many of the entries have case



                                                              xiii
xiv                                                      Preface

descriptions to illustrate the specifics of theory and          for approval and/or further modification. All entries
technique. The topics addressed span clinical, theoret-        were reviewed on the basis of accuracy, completeness,
ical, cultural, historical, and administrative and policy      clarity, brevity, and the absence of polemics. The result-
issues, as well as the matters of schools and specific          ing Encyclopedia of Psychotherapy is a product of com-
patient conditions. Most importantly, a comprehensive          plete collaboration between the two editors-in-chief, and
user friendly Index is provided.                               hence the order of editorship is alphabetical.
   Early on it was apparent that a project of this magni-         We are grateful to the many individuals who helped
tude would require associate editors and an advisory           make the Encyclopedia of Psychotherapy possible.
board to ensure broad coverage of issues and topics.           Thank you to the four associate editors who performed
The inclusion of these colleagues has added immeasur-          in an exemplary fashion. Thank you also to our 18
ably to the fruition of this work. The associate editors       members of the advisory board for their wise counsel
(Alan M. Gross, Ph.D, Jerald Kay, M.D., Bruce J. Roun-         and excellent suggestions. Thanks also to our contribu-
saville, M.D., Warren W. Tryon, Ph.D.) were chosen in          tors who took time out from their busy schedules to be-
order to represent the cross-fertilization between the         come part of our project, sharing their expertise as well
medical and the psychological, adult and child, theo-          as articulating their views on where this field stands.
retical and pragmatic, research and practice, and behav-       We thank Alex Duncan, Angelina Marchand, and An-
ioral and non-behavioral. Similarly, the 18 advisory           gelina Basile for their research efforts. We appreciate
board members (both M.D.s and Ph.D.s) were selected            Carole Londeree’s technical assistance. We thank all at
because of their broad range of interests and expertise        Academic Press who were involved in the production
in all aspects of the psychotherapeutic endeavor.              effort, especially the acquisitions editor, George Zim-
   The iterative process began with a large list of topics     mar, and the coordinator of the Encyclopedia, Anya Ko-
selected by the two editors-in-chief, which was then re-       zorez, for helping us to conceptualize this work and
fined by the associate editors and the advisory board           overcome obstacles to see it through to publication.
members. Excellent suggestions for authors were made              We dedicate this work to our colleagues who work
and the solicitation process began. When received by           on a daily basis to relieve the suffering of their clients.
Academic Press, each entry was evaluated by an appro-
priate associate editor, revised to the editor’s specifica-                                                Michel Hersen
tions, and then sent on to one of the two editors-in-chief                                                William Sledge
                                Contents of Volume 1

  Acceptance and Commitment Therapy; Kirk Strosahl;                                          1-8
  Addictions in Special Populations: Treatment; Paul R. Stasiewicz and Kellie E. Smith;    9-14
  Adjunctive/Conjoint Therapies; Robert Ostroff;                                          15-22
  Adlerian Psychotherapy; Henry T. Stein and Martha E. Edwards;                           23-31
  Alternatives to Psychotherapy; Janet L. Cummings;                                       33-40
  Anger Control Therapy; Raymond W. Novaco;                                               41-48
  Animal-Assisted Therapy; Aubrey H. Fine;                                                49-55
  Anxiety Disorders: Brief Intensive Group Cognitive Behavior Therapy;
     Tian P. S. Oei and Genevieve Dingle;                                                 57-60
  Anxiety Management Training; Richard M. Suinn and Jerry L. Deffenbacher;                61-69
  Applied Behavior Analysis; Alan E. Kazdin;                                              71-94
  Applied Relaxation; Lars-Goran Ost;                                                    95-102
  Applied Tension; Lars-Goran Ost;                                                      103-108
  Arousal Training; Marita P. McCabe;                                                   109-112
  Art Therapy; Marcia Sue Cohen-Liebman;                                                113-116
  Assertion Training; Eileen Gambrill;                                                  117-124
  Assisted Covert Sensitization; Joseph J. Plaud;                                       125-130
  Attention Training Procedures; Alice Medalia;                                         131-137
  Aversion Relief; Paul M. G. Emmelkamp and j. H. Kamphuis;                             139-143
  Avoidance Training; James K. Luiselli;                                                145-148
  Backward Chaining; Douglas W. Woods and Ellen J. Teng;                                149-153
  Beck Therapy Approach; Judith S. Beck;                                                155-163
  Behavioral Assessment; David C. S. Richard and Stephen N. Haynes;                     165-183
  Behavioral Case Formulation; Jennifer R. Antick and Johan Rosqvist;                   185-190
  Behavioral Consultation Therapy; Mark E. Ehrlich and Thomas R. Kratochwill;           191-205
  Behavioral Contracting; Brad Donohue and Lisa Solomon Weissman;                       207-211
  Behavioral Group Therapy; Brian J. Cox and Steven Taylor;                             213-221
  Behavioral Marital Therapy; Gary R. Birchler;                                         223-231
  Behavioral Therapy Instructions; Amy M. Combs-Lane, Joanne L. Davis,
    Adrienne E. Fricker and Ron Acierno;                                                233-236
  Behavioral Treatment of Insomnia; Jack D. Edinger;                                    237-242
  Behavioral Weight Control Therapies; Donald A. Williamson,
    Joy R. Kohlmaier and Marney A. White;                                               243-251
  Behavior Rehearsal; Arnold A. Lazarus;                                                253-257


Encyclopedia of Psychotherapy                                             Copyright 2002, Elsevier Science (USA).
                                               xv                                             All rights reserved.
   Behavior Therapy: Historical Perspective and Overview; John P. Forsyth
     and Jill Sabsevitz;                                                                      259-275
   Behavior Therapy: Theoretical Bases; Dean McKay and Warren W. Tryon;                       277-291
   Bell-and-Pad Conditioning; Daniel M. Doleys and Brad B. Doleys;                            293-300
   Biblical Behavior Modification; Linda Wasserman;                                           301-307
   Bibliotherapy; Eileen Gambrill;                                                            309-315
   Bioethics; Everett K. Spees;                                                               317-330
   Biofeedback; Doil D. Montgomery;                                                           331-344
   Breathing Retraining; Ronald Ley;                                                          345-348
   Brief Therapy; Brett N. Steenbarger;                                                       349-358
   Cancer Patients: Psychotherapy; David Spiegel;                                             359-364
   Chaining; Ruth Anne Rehfeldt;                                                              365-369
   Character Pathology; Donna S. Bender and Andrew E. Skodol;                                 371-379
   Child and Adolescent Psychotherapy: Psychoanalytic Principles; Steven Marans,
     Kirsten Dahl and John Schowalter;                                                       381-400
   Cinema and Psychotherapy; Irving Schneider;                                               401-406
   Clarification; W. W. Meissner;                                                            407-413
   Classical Conditioning; Steven Taylor;                                                    415-429
   Cognitive Appraisal Therapy; Richard L. Wessler;                                          431-434
   Cognitive Behavior Group Therapy; Sheldon D. Rose;                                        435-450
   Cognitive Behavior Therapy; Deborah A. Roth Winnie Eng and
     Richard G. Heimberg;                                                                    451-458
   Collaborative Care; Nicholas A. Cummings;                                                 459-467
   Communication Skills Training; David Reitman and Nichole Jurbergs;                        469-473
   Comorbidity; William M. Klykylo;                                                          475-479
   Competing Response Training; Raymond G. Miltenberger;                                     481-485
   Complaints Management Training; Gudrun Sartory and Karin Elsesser;                        487-493
   Conditioned Reinforcement; Ben A. Williams;                                               495-502
   Confidentiality; Norman Andrew Clemens;                                                   503-510
   Configurational Analysis; Mardi J. Horowitz;                                              511-515
   Confrontation; W. W. Meissner;                                                            517-524
   Contingency Management; Christopher A. Kearney and Jennifer Vecchio;                      525-532
   Controlled Drinking; Harold Rosenberg;                                                    533-544
   Control-Mastery Theory; Joseph Weiss;                                                     545-549
   Corrective Emotional Experience; Deborah Fried;                                           551-555
   Correspondence Training; Karen T. Carey;                                                  557-560
   Cost Effectiveness; William H. Sledge and Susan G. Lazar;                                 561-568
   Countertransference; William H. Sledge;                                                   569-572
   Couples Therapy: Insight-Oriented; Douglas K. Snyder;                                     573-577
   Coverant Control; E. Thomas Dowd;                                                         579-585
   Covert Positive Reinforcement; Gerald Groden and June Groden;                             587-592
   Covert Rehearsal; Zehra F. Peynirciolu;                                                   593-597
   Covert Reinforcer Sampling; Patricia A. Wisocki;                                          599-602
   Cultural Issues; Edward F. Foulks;                                                        603-613
   Danger Ideation Reduction Therapy; Mairwen K. Jones and Ross G. Menzies;                  615-619
   Dialectical Behavior Therapy; Sarah K. Reynolds and Marsha M. Linehan;                    621-628


Encyclopedia of Psychotherapy                                           Copyright 2002, Elsevier Science (USA).
                                              xvi                                           All rights reserved.
  Differential Attention; Nirbhay N. Singh, Bethany A. Marcus and
    Ashvind N. Singh;                                                                    629-632
  Differential Reinforcement of Other Behavior; Marc J. Tasse,
    Susan M. Havercamp and Luc Lecavalier;                                              633-639
  Discrimination Training; Lisa W. Coyne and Alan M. Gross;                             641-646
  Documentation; Norman Andrew Clemens;                                                 647-653
  Dosage Model; S. Mark Kopta and Jenny L. Lowry;                                       655-660
  Dreams, Use in Psychotherapy; Robert C. Lane and Max Harris;                          661-669
  Eating Disorders; Joel Yager;                                                         671-680
  Economic and Policy Issues; Nicholas A. Cummings;                                     681-701
  Education: Curriculum for Psychotherapy; James W. Lomax;                              703-708
  Effectiveness of Psychotherapy; Michael J. Lambert and David A. Vermeersch;           709-714
  Efficacy; Michael J. Lambert and Melissa K. Goates;                                   715-718
  Electrical Aversion; Nathaniel McConaghy;                                             719-730
  Emotive Imagery; Arnold A. Lazarus;                                                   731-734
  Engagement; Georgiana Shick Tryon;                                                    735-739
  Existential Psychotherapy; Paul B. Lieberman and Leston L. Havens;                    741-754
  Exposure; Steven Taylor;                                                              755-759
  Exposure in Vivo Therapy; Wiljo J. P. J. van Hout and Paul M. G. Emmelkamp;           761-768
  Extinction; Alan Poling, Kristal E. Ehrhardt and R. Lanai Jennings;                   769-775
  Eye Movement Desensitization and Reprocessing; Francine Shapiro
    and Louise Maxfield;                                                                 777-785
  Fading; Cynthia M. Anderson;                                                           787-791
  Family Therapy; William A. Griffin;                                                    793-800
  Feminist Psychotherapy; Carolyn Zerbe Enns;                                            801-808
  Flooding; Catherine Miller;                                                            809-813
  Formulation; Tracy D. Eells;                                                           815-822
  Forward Chaining; Raymond G. Miltenberger;                                             823-827
  Free Association; Anton O. Kris;                                                       829-831
  Functional Analysis of Behavior; Kelly G. Wilson and Amy R. Murrell;                   833-839
  Functional Analytic Psychotherapy; Robert J. Kohlenberg and Mavis Tsai;                841-845
  Functional Communication Training; Cynthia R. Johnson;                                 847-852
  Gambling: Behavior and Cognitive Approaches; Robert Ladouceur,
     Claude Boutin, Caroline Sylvain and Stella Lachance;                               853-862
  Gestalt Therapy; Stephen G. Zahm and Eva K. Gold;                                     863-872
  Gifted Youth; Douglas Schave;                                                         873-878
  Good Behavior Game; Daniel H. Tingstrom;                                              879-884
  Grief Therapy; Rostyslaw W. Robak;                                                    885-889
  Group Psychotherapy; K. Roy MacKenzie;                                                891-906
  Guided Mastery Therapy; Asle Hoffart;                                                 907-910
  Habit Reversal; Raymond G. Miltenberger;                                              911-917
  Heterosocial Skills Training; Eric Strachan and Debra A. Hope;                        919-924
  History of Psychotherapy; David Bienenfeld;                                           925-935
  Home-Based Reinforcement; Douglas W. Woods and Michael P. Twohig;                     937-941
  Homework; Lisa W. Coyne and Thomas W. Lombardo;                                       943-947
  Humanistic Psychotherapy; Kirk J. Schneider and Larry M. Leitner;                     949-957



Encyclopedia of Psychotherapy                                       Copyright 2002, Elsevier Science (USA).
                                            xvii                                        All rights reserved.
                                    Contents of Volume 2

                                Note: Pages of Volume 2 have prefix ‘b’ (b1, b2, …)



    Implosive Therapy; Donald J. Levis;                                              1-6
    Individual Psychotherapy; Larry E. Beutler and T. Mark Harwood;                 7-15
    Informed Consent; Catherine Miller;                                            17-24
    Integrative Approaches to Psychotherapy; Jerry Gold;                           25-35
    Interpersonal Psychotherapy; Scott Stuart and Michael Robertson;               37-47
    Interpretation; T. Wayne Downey;                                               49-56
    Intrapsychic Conflict; Alan Sugarman;                                          57-62
    Job Club Method; Nathan H. Azrin;                                              63-67
    Jungian Psychotherapy; Jeffrey Satinover;                                      69-81
    Language in Psychotherapy; W. Rand Walker;                                     83-90
    Legal Dimensions of Psychotherapy; Howard Zonana;                             91-105
    Logotherapy; Paul T. P. Wong;                                                107-113
    Manualized Behavior Therapy; Michael J. Zvolensky and Georg H. Eifert;       115-121
    Matching Patients to Alcoholism Treatment; Margaret E. Mattson;              123-129
    Medically Ill Patient: Psychotherapy; Randy A. Sansone and Lori A. Sansone;  131-139
    Minimal Therapist Contact Treatments; Anderson B. Rowan and Julie M. Storey; 141-145
    Modeling; Kurt A. Freeman;                                                   147-154
    Mood Disorders; Michael Robertson and Scott Stuart;                          155-164
    Multicultural Therapy; David Sue;                                            165-173
    Multimodal Behavior Therapy; Arnold A. Lazarus;                              175-182
    Negative Practice; Theodosia R. Paclawskyj and Johnny L. Matson;             183-188
    Negative Punishment; Alan Poling, John Austin, Susan Snycerski
       and Sean Laraway;                                                         189-197
    Negative Reinforcement; Alan Poling, Linda A. LeBlanc and Lynne E. Turner;   199-205
    Neurobiology; Douglas S. Lehrer and Jerald Kay;                              207-221
    Neuropsychological Assessment; Linda Laatsch;                                223-228
    Nocturnal Enuresis: Treatment; Henry S. Roane, Cathleen C. Piazza and
       Mary A. Mich;                                                             229-233
    Objective Assessment; James N. Butcher;                                      245-248
    Object-Relations Psychotherapy; Frank Summers;                               235-244
    Oedipus Complex; Jodi H. Brown and Alan Sugarman;                            249-256


Encyclopedia of Psychotherapy                                                  Copyright 2002, Elsevier Science (USA).
                                                       xviii                                       All rights reserved.
    Omission Training; Ruth Anne Rehfeldt;                                                    257-260
    Online or E-Therapy; Zebulon Taintor;                                                     261-270
    Operant Conditioning; Alan Poling, James E. Carr and Linda A. LeBlanc;                    271-287
    Organic Brain Syndrome: Psychotherapeutic and Rehabilitative Approaches;
      Avraham Schweiger and Jason W. Brown;                                                  289-297
    Orgasmic Reconditioning; Nathaniel McConaghy;                                            299-305
    Outcome Measures; Michael J. Lambert and Dean E. Barley ;                                307-311
    Overcorrection; Steven A. Hobbs, Benjamin A. Jones and Julie Stollger Jones;             313-317
    Pain Disorders; Douglas A. Songer;                                                       319-324
    Panic Disorder and Agoraphobia; Stefan G. Hofmann;                                       325-330
    Paradoxical Intention; L. Michael Ascher;                                                331-338
    Parent-Child Interaction Therapy; Brendan A. Rich, Jane G. Querido and
       Sheila M. Eyberg;                                                                     339-347
    Patient Variables: Anaclitic and Introjective Dimensions; Sidney J. Blatt;               349-357
    Positive Punishment; Alan Poling, Kristal E. Ehrhardt and Ruth A. Ervin;                 359-366
    Positive Reinforcement; Alan Poling and Edward J. Daly III;                              367-372
    Posttraumatic Stress Disorder; Ann E. Norwood and Robert J. Ursano;                      373-378
    Primary Care Behavioral Pediatrics; Patrick C. Friman and Nathan Blum;                   379-399
    Progressive Relaxation; Rachel L. Grover and Douglas W. Nangle;                          401-407
    Projective Testing in Psychotherapeutics; J. Christopher Fowler;                         409-414
    Psychoanalysis and Psychoanalytic Psychotherapy: Technique;
       Stephen M. Sonnenberg and Robert J. Ursano;                                           415-422
    Psychoanalytic Psychotherapy and Psychoanalysis, Overview; Eric R. Marcus;               423-430
    Psychodynamic Couples Therapy; Francine Cournos;                                         431-437
    Psychodynamic Group Psychotherapy; Walter N. Stone;                                      439-449
    Psychodynamic Voice Disorders: Treatment; E. Charles Healey
       and Marsha Sullivan;                                                                  451-455
    Psychopharmacology: Combined Treatment; Jerald Kay;                                      457-465
    Race and Human Diversity; Sandra Jenkins;                                                467-481
    Rational Emotive Behavior Therapy; Albert Ellis;                                         483-487
    Reality Therapy; Robert E. Wubbolding;                                                   489-494
    Reinforcer Sampling; Adrienne E. Fricker, Amy M. Combs-Lane,
       Joanne L. Davis and Ron Acierno;                                                       495-497
    Relapse Prevention; Kirk A. Brunswig, Tamara M. Penix and
      William O'Donohue;                                                                      499-505
    Relational Psychoanalysis; Spyros D. Orfanos;                                             507-513
    Relaxation training; Daniel W. McNeil and Suzanne M. Lawrence;                            515-523
    Research in Psychotherapy; Karla Moras; 52-4
    Resistance; Kay McDermott Long and William H. Sledge;                                    547-552
    Response-Contingent Water Misting; J. Grayson Osborne;                                   553-560
    Response Cost; Saul Axelrod;                                                             561-564
    Restricted Environmental Stimulation Therapy; Jeanne M. Bulgin,
       Arreed F. Barabasz and W. Rand Walker;                                                 565-569
    Retention Control Training; Kurt A. Freeman and Elizabeth T. Dexter;                      571-575
    Role-Playing; Joanne L. Davis, Adrienne E. Fricker, Amy M. Combs-Lane
       and Ron Acierno;                                                                       577-580
    Schizophrenia and Other Psychotic Disorders; Richard L. Munich ;                          581-590


Encyclopedia of Psychotherapy                                          Copyright 2002, Elsevier Science (USA).
                                              xix                                          All rights reserved.
    Self-Control Desensitization; E. Thomas Dowd;                                            591-593
    Self-Control Therapy; Lynn P. Rehm and Elisia V. Yanasak;                                595-600
    Self-Help Groups; Gary M. Burlingame and D. Rob Davies;                                  601-605
    Self-Help Treatment for Insomnia; Annie Vallieres, Marie-Christine Ouellet
      and Charles M. Morin;                                                                  607-613
    Self Psychology; Arnold Wilson and Nadezhda M. T. Robinson;                              615-620
    Self-Punishment; Rosiana L. Azman;                                                        621-624
    Self-Statement Modification; E. Thomas Dowd;                                             625-628
    Setting Events; Mark R. Dixon;                                                           629-633
    Sex Therapy; Heather J. Meggers and Joseph LoPiccolo;                                    635-650
    Short-Term Anxiety-Provoking Psychotherapy; John Tsamasiros;                             651-657
    Single-Case Methods and Evaluation; Graham Turpin;                                       659-668
    Single-Session Therapy; Brett N. Steenbarger;                                            669-672
    Solution-Focused Brief Therapy; Anne Bodmer Lutz and Insoo Kim Berg;                     673-678
    Somatoform Disorders; Ann Kerr Morrison;                                                 679-685
    Sports Psychotherapy; Todd C. O'Hearn;                                                   687-692
    Spouse-Aided Therapy; Paul M. G. Emmelkamp and Ellen Vedel;                              693-697
    Stretch-Based Relaxation Training; Charles R. Carlson;                                   699-705
    Structural Analysis of Social Behavior; Lorna Smith Benjamin;                            707-713
    Structural Theory; Alan Sugarman;                                                         715-719
    Substance Dependence: Psychotherapy; Kathlene Tracy, Bruce Rounsaville
       and Kathleen Carroll;                                                                 721-730
    Successive Approximations; Patricia A. Wisocki;                                          731-732
    Sullivan's Interpersonal Psychotherapy; Maurice R. Green;                                733-740
    Supervision in Psychotherapy; Stephen B. Shanfield;                                      741-744
    Supportive-Expressive Dynamic Psychotherapy; Lester Luborsky;                            745-750
    Symbolic Modeling; Michael A. Milan;                                                     751-753
    Systematic Desensitization; F. Dudley McGlynn;                                           755-764
    Tele-Psychotherapy; Ann Oberkirch;                                                       765-775
    Termination; Georgiana Shick Tryon;                                                      777-779
    Therapeutic Factors; T. Byram Karasu;                                                    781-791
    Therapeutic Storytelling with Children and Adolescents; Everett K. Spees;                793-801
    Thought Stopping; Melanie L. O'Neill and Maureen L. Whittal;                             803-806
    Time-Limited Dynamic Psychotherapy; Hanna Levenson,
       Thomas E. Schacht, Hans H. Strupp;                                                     807-814
    Timeout; Rebecca S. Griffin and Alan M. Gross;                                            815-819
    Token Economy; Paul Stuve and Julian A. Salinas;                                          821-827
    Token Economy: Guidelines for Operation; Teodoro Ayllon
      and Michael A. Milan;                                                                  829-833
    Topographic Theory; Alan Sugarman and Keith Kanner;                                      835-839
    Transcultural Psychotherapy; Thomas E. Heise;                                            841-850
    Transference; Eric R. Marcus;                                                            851-854
    Transference Neurosis; Alan Sugarman and Claudia Law-Greenberg;                          855-859
    Transitional Objects and Transitional Phenomena; Arnold Wilson
      and Nadezhda M. T. Robinson;                                                            861-866
    Trauma Management Therapy; B. Christopher Frueh Samuel M. Turner
      and Deborah C. Beidel;                                                                  867-873


Encyclopedia of Psychotherapy                                          Copyright 2002, Elsevier Science (USA).
                                              xx                                           All rights reserved.
   Unconscious, The; Alan Sugarman and Caroline DePottel;                           875-879
   Vicarious Conditioning; E. Thomas Dowd;                                           881-883
   Vicarious Extinction; E. Thomas Dowd;                                             885-887
   Virtual Reality Therapy; Max M. North and Sarah M. North;                        889-893
   Vocational Rehabilitation; Ruth Crowther;                                         895-900
   Women's Issues; Malkah T. Notman and Carol C. Nadelson;                          901-908
   Working Alliance; Georgiana Shick Tryon;                                          909-912
   Working Through; Mark J. Sedler;                                                  913-916




Encyclopedia of Psychotherapy                                  Copyright 2002, Elsevier Science (USA).
                                        xxi                                        All rights reserved.
                                                A
                                  Acceptance and
                                Commitment Therapy
                                                         Kirk Strosahl
                                                 Mountainview Consulting Group, Inc.




    I.   Theoretical Bases of ACT                                          Acceptance and commitment therapy (ACT) is a
   II.   Description of ACT Treatment                                   contextually based cognitive behavioral treatment. The
  III.   Empirical Studies of ACT                                       ACT model holds that culturally supported attempts to
  IV.    Summary                                                        control and eliminate unpleasant private experiences
         Further Reading
                                                                        (i.e., negative emotions, thoughts, memories) result in
                                                                        personal suffering, behavior disorders, and a lack of
                                                                        vital and purposeful living. ACT attempts to teach
                            GLOSSARY                                    clients to accept, rather than control or eliminate, pri-
                                                                        vate experiences that are not amenable to first order
cognitive fusion The act of perceiving private experiences
                                                                        change. Acceptance is accomplished through teaching
    such as thoughts and feelings from the perspective struc-
                                                                        the client to see these private experiences as condi-
    tured by the private event itself rather than the perspective
    of an observer of that event as a process. Reducing fusion          tioned verbal responses, rather than literal truth. ACT
    is a key target of meditation, mindfulness, and deliteraliza-       emphasizes that the client approach, rather than avoid,
    tion interventions in ACT.                                          valued life goals, even though pursuing such goals may
cultural change agenda The culturally sanctioned model                  stimulate “uncomfortable” private experiences.
    most clients bring into therapy holds that the goal is to
    gain control of and eliminate negative personal content.
    This agenda for changing from an unhealthy person with                    I. THEORETICAL BASES OF ACT
    “issues” to a healthy person without “issues” has the para-
    doxical effect of increasing suffering.                                Acceptance and commitment therapy is unique
literality The capacity of representational thought and lan-            among the cognitive behavioral therapies in that it is
    guage to take on literal meaning and for the derived stimu-         theoretically derived from relational frame theory
    lus functions of referents to dominate over other sources of        (RFT). RFT is a post-Skinnerian behavior analytic ac-
    behavior. An example is “anticipatory panic attacks,”               count of the functional properties of human language
    which result from simply imagining being in a panic asso-
                                                                        and thought, developed by Steven Hayes and other be-
    ciated situation, such as a mall or elevator, and then taking
                                                                        havior analytic researchers around the world. Hayes and
    those thoughts literally.
relational frame theory (RFT) A post-Skinnerian account of              colleagues conducted two decades of basic research to
    the structural and functional properties of human lan-              validate the core principles of RFT before introducing
    guage and thought that is based in contextual behaviorism.          the ACT therapy model. As we shall see, many ACT in-
    RFT views language and thought as relational behavior               terventions are based in RFT principles and are designed
    that is controlled by learning factors.                             to influence the contextual and functional characteristics



Encyclopedia of Psychotherapy                                                                      Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                            1                                                  All rights reserved.
2                                         Acceptance and Commitment Therapy

of language and thought. There are several principles of     ronment. In ACT, this is referred to as the hegemony of
RFT that are directly relevant to both the development       language.
of human suffering and psychopathology, as well as clin-        A third key principle of RFT is that there are distinct
ical interventions.                                          functional properties of language and thought that ex-
   First, it is not functionally useful to separate the      plain not only the tremendous evolutionary advantage
functions of human language and thought from the             of human thought, but also its “dark side.” The bidirec-
contextual field in which the human organism oper-            tionality of human language enables humans to pro-
ates. These processes are learned, reinforced, and recip-    duce pain simply by remembering past pain or
rocally governed in the same fashion as any other            anticipating it in the future. For that reason, humans
learned human behavior. In RFT, language and thought         cannot regulate their psychological discomfort by es-
are a special form of relational behaviors that enable       caping aversive situations, and instead begin to attempt
the human organism to relate events bidirectionally          to avoid or modify emotions. Thus, emotional avoid-
and in combination, whereas direct experience is only        ance is built into human language. Many unique forms
unidirectional. For example, learning that a ball is         of human behavior (e.g., humans are the only species
called “ball” enables the human to look for and orient       known to commit suicide), seem to be a side effect of
toward the ball when later hearing “ball.” This simple       this process.
process is apparently absent in nonhumans, but occurs           Relational behavior in turn enables rule-governed
in human infants by about 14 months.                         behavior: the generation of verbal formula to use in
   A second critical RFT principle is that the context or    guiding human action. Unlike contingency governed
“field” of language and thought involves both exter-          actions, which are shaped systematically through direct
nally and internally generated verbal relations. The ex-     trial and error (e.g., learning to ride a bicycle), rule-
ternal context is the verbal community, consisting of        governed behaviors are developed through the verbal
verbally transmitted cultural practices (i.e., the lan-      specification of contingencies, rather than through di-
guage called “English” is what you will speak), social       rect contact with them. This form of learning greatly
influence and consequence (i.e., you need to justify          expands the potential for learning important rules
with the correct set of words why you hit someone,           without having to make direct contact with the contin-
otherwise you get punished), and interpersonal influ-         gencies specified by those rules.
ence (i.e., if you don’t give a good reason why you hit         There are many different types of rule-governed
Johnny, you will get a spanking). The development of a       classes that have clinical significance. Augmentation
culturally compliant human organism is dependent on          involves a rule that changes motivation, typically by
this process. The main vehicle of cultural transmission      relating some immediate situation with a verbally con-
is the process of language acquisition and refinement.        structed set of future contingencies. For example, a
Eventually, language is experienced covertly in the          young college student might be highly motivated to
form of thinking. The internal context is the relation-      study by having images of getting a high-paying job
ship between the thought and the thinker. Humans             several years hence (i.e., a motivative augmental).
have the ability to “receive” thoughts, weigh their mer-     Getting an “A” on an important exam is reinforcing be-
its (using other thoughts) and produce an action justi-      cause of the augmenting effect of the future contingen-
fied in terms of the second set of thoughts. The             cies. The consequence is the persistence of studying
complexity of this constantly evolving set of relation-      behavior. Pliance is a more basic form of rule-governed
ships, combined with a constant reciprocal interaction       behavior. “Plys” are rules that influence the person
with the verbal community, requires that humans en-          to behave in culturally sanctioned ways. Telling a cry-
gage in hundreds of thousands of language and thought        ing child, “Be a good boy now and stop crying,” is in
transactions daily, much of them beneath the level of        effect saying to please the parents by stopping the act
conscious awareness. The result is that humans be-           of crying. The child may stop crying, even though sig-
come so dependent on these symbolic processes that           nificant physical discomfort is present. Tracking is an-
they cease to recognize them for what they are: arbi-        other common form of rule following that involves
trarily derived relations between verbal stimuli. When       establishing a relationship between a rule and a set
this occurs, the dominance of language and thought           of nonarbitrary contingencies. A track might involve
can become so excessive that the organism ceases to          responding to a weather report that calls for record
adapt to the demands of the environment and, instead,        cold temperatures by securing a heavier coat, because
is controlled by symbolic representations of the envi-       past history has established a relationship between the
                                                 Acceptance and Commitment Therapy                                          3
temperature outside and the type of clothing that pro-              deviations from a natural state of psychological health.
duces warmth.                                                       When confronted with negative personal experience,
   Because of the general utility of rules, a pervasive             the socially sanctioned response is directly analogous
consequence for rule-governed behavior is sense mak-                to the process used to handle challenges in the exter-
ing. It appears that humans are highly motivated to                 nal world. Specifically, first one identifies the cause of
organize derived relations within an overarching frame-             the problem, then employs strategies designed to elim-
work that helps them “make sense” of these relation-                inate the cause and, through the causal chain, the
ships. Independent of whether the relationships are                 problem itself.
factually correct, humans will create this type of con-                In contrast, the ACT approach holds that suffering
ceptual order. In ACT, this is referred to as the “context          and dysfunction arise from following these culturally
of reason giving.”                                                  sanctioned, but ineffective, rules for coping with dis-
   The ACT account of human pathology applies RFT                   tressing experiences. Paradoxically, the use of control
principles to the larger rule-governed context of                   and elimination strategies leads to greater suffering and
human behavior. First, RFT research has established                 an apparent loss of control of the symptoms to be elim-
that, for all their evolutionary utility, rule-governed be-         inated. In ACT, this is termed the “rule of mental
haviors are extremely resistant to the mitigating effects           events.” Specifically, the less one is willing to have a
of direct experience. At the same time, these change-re-            problematic private experience, the more one gets of it.
sistant features are hidden in the very structure of lan-           There is significant research to support this core feature
guage and thought. A brief clinical example will                    of human experience. For example, the thought sup-
highlight how basic RFT principles directly convert                 pression literature demonstrates that suppression and
into clinical dysfunction:                                          control strategies produce an upsurge in unwanted
                                                                    thoughts, and increased distress. Ironically, the strate-
      A woman who was sexually abused as a child reports            gies that have produced so much success for the
   persistent problems with extreme fearfulness when en-            human species in the external world are the cause of
   gaging in any kind of intimate behavior with a new               suffering and psychopathology when applied to events
   boyfriend. She reports having the same kinds of experi-          “between the ears.” The reasonable, normal, sensible
   ences she remembers having when she was being sexu-              things people do to address suffering in fact generates
   ally victimized (based on a “frame of coordination”              suffering. In ACT, this is referrred to as the problem of
   between the two events). She reports being unable to             unhealthy normality. Clients do not present for treat-
   trust her male friend even though there is evidence that         ment because they are “broken,” but because they are
   he is different than her abusive father (a “transforma-
                                                                    trapped in an unworkable culturally supported change
   tion of functions” through that frame of coordination).
                                                                    agenda.
   She has been taught that the key to a fulfilling life is to
   form a positive intimate relationship, and has contin-              The cultural change agenda is supported by basic
   ued dating so as not to disappoint her mother (pliance).         rule-governed behaviors that normally are not within
   She is frustrated and angry with herself because she be-         the awareness of the client. In ACT, these core dysfunc-
   lieves she is “defective” due to her childhood abuse his-        tional responses are described in the FEAR model of
   tory. The proof of this is healthy people are able to trust      suffering:
   others in intimate relationships and she cannot (sense              Fusion: This is the tendency of humans to merge with
   making). She has decided to stop dating because she              the content of their private experiences, leading to the
   believes her fear, mistrust, and disappointment will just        problem of literality. Literality means that the distinc-
   get worse (augmentation). She wonders what she ever              tion has been lost between symbolic activity and the
   did to deserve being abused.
                                                                    event that acts as its referent. In the example above, the
                                                                    woman is fusing historically learned physical and emo-
   When a person encounters negative personal con-                  tional symptoms (from the original trauma) with a con-
tent such as in the sexual abuse vignette, culturally               ceptually similar current event (intimate relations with
transmitted, verbally based responses are activated                 her boyfriend) and attributing her reactions to the cur-
that determine both the outcome to be achieved and                  rent event. She has fused the emotional and physical
the processes needed to achieve it. Basic social pro-               properties of a distant event with a minimally similar
gramming suggests that “health” is measured by the                  current event. Hence, her verbal formulation suggests
absence of negative psychological content. In western               she has trust issues, whereas the core issue is her fusion
culture, psychopathology and suffering are viewed as                with historically conditioned responses.
4                                         Acceptance and Commitment Therapy

   Evaluation: This is the tendency of humans to cate-       vate experience such as a negative thought, feeling,
gorize and attribute qualities to referents, as though       memory, or physical sensation: Second, describe the
they are primary properties of the referents. An exam-       predisposing private experience as a cause of the result-
ple of major evaluative themes in psychopathology            ing behavior. In the example above, the woman pres-
and human suffering are “good-bad,” “right-wrong,”           ents her problem as being linked historically to her
or “fair-unfair.” Through the process of fusion, evalu-      sexual abuse. The sexual abuse is used to explain her
ations become inseparable from the events they are           fear experiences during intimacy. She then justifies her
intended to qualify. In the example above, the woman         lack of intimacy behavior by setting her private experi-
states she is defective, as if defective was a primary       ences in opposition to the desired outcome (i.e., one
property at the level of being. In truth, she is a           cannot be intimate while being afraid; fear causes the
woman who is having the self-evaluative thought              loss of intimacy). In the end, she has “justified” why in-
called, “I am defective.” She indicates that healthy         timacy is impossible and why she is entitled to cease ef-
people do not have these issues, a form of good-bad          forts in that area.
attribution. She wonders what she did to deserve the            Reason giving is a pervasive issue in human dysfunc-
abuse, essentially imbuing life with some independ-          tion for many reasons, but two are worth noting. First,
ent property of fairness.                                    not only do humans have extremely limited access to
   Avoidance: Due to the impact of bidirectionality and      the vast multitude of influences that shape their learn-
rule-governed behavior, humans are inclined to avoid         ing history, but also there is no convincing evidence
the situational or representational “triggers” for un-       that private events “cause” behavior. The client’s story
pleasant consequences. Paradoxically, this type of ex-       is an arbitrary set of internally consistent, culturally
periential avoidance may stimulate feared or unwanted        shaped and sanctioned reasons that probably bears lit-
private experiences such as thoughts, feelings, memo-        tle resemblance to a complete historical analysis. Sec-
ries, or bodily sensations. There is a significant empir-     ond, most forms of therapy are rooted in the verbal
ical literature demonstrating the unhealthy effects of       community and consequently a premium is placed on
experiential avoidance, even in nonpsychiatric sam-          giving “good” reasons for being distressed and dysfunc-
ples. It is implicated as a primary mechanism in nu-         tional. Not only is the abused woman giving an inaccu-
merous mental and chemical dependency disorders.             rate account of her learning history (focusing on the
Experiential avoidance is almost always predicated on        sexual abuse and ignoring a multitude of other learning
the mistaken belief that, by avoiding participation in       factors), proposing an unlikely cause–effect relation-
challenging life events, one will not have to experience     ship (her fear “causes” her to stop being intimate), but
the uncomfortable private experiences associated with        very likely will have this “story” tacitly endorsed by the
participation. In the example above, the woman indi-         therapist.
cates she has decided to stop dating, rather than expe-
rience continued fear, mistrust, and relationship
failure. Paradoxically, it is precisely by withdrawing                     II. DESCRIPTION
from the “field of play” that her childhood trauma ex-                     OF ACT TREATMENT
erts its maximum negative influence over her life.
Each day spent not participating lends credence to her          ACT seeks to accomplish several major results. The
notion that she is “defective,” elevates her anticipatory    first is to help the client use direct experience, instead
fear response about accidentally meeting a soul mate,        of rule following, to discover more effective responses
and deprives her of the opportunity to practice being        to the challenges of being alive. The second is to dis-
intimate while being afraid.                                 cover that control and elimination strategies are the
   Reason Giving: This is the tendency to present rea-       cause of suffering, not the cure for suffering. The third
sons that explain the cause of particular forms of pri-      is to realize that acceptance and willingness are viable
vate experience and/or behavior. In essence, the             alternatives to struggle, control, and elimination. The
cultural context of language and thought teaches hu-         fourth is to understand that acceptance is made possi-
mans to give socially sanctioned reasons for behavior,       ble by learning to detach from the rule-governing ef-
especially behavior that is out of the perceived cultural    fects of language and thought. The fifth is to realize
norm. The most common reason-giving strategy is a            that the basic, unchanging self as consciousness is a
two-step process: First, describe a set of historical in-    place from which acceptance and committed action
fluences that hypothetically explain a predisposing pri-      can occur. The final result is the understanding that
                                          Acceptance and Commitment Therapy                                              5
the road to vitality, purpose, and meaning is a journey      human suffering unfolds and, consequently, to how
consisting of choosing valued actions that are per-          ACT might unfold.
formed in the service of valued life ends. In ACT, the
response to the life-limiting effects of FEAR is:                        A. First Thematic Stage:
                        Accept                                           Creative Hopelessness
                        Choose
                                                                The goal of creative hopelessness is to help the
                      Take action
                                                             client determine that the cultural change agenda is un-
   To many clients, the notion of turning around and         workable. The change agenda the client typically
embracing feared memories, hidden insecurities, per-         brings into therapy is to determine the cause of suffer-
ceived shortcomings, and negative personal history is        ing and then to eliminate the cause, so the problem
frightening. The grip of self-limiting, rule-governed re-    will dissipate. This typically converts into a cause and
sponses is so complete that clients cannot even see the      effect statement: “If I had more confidence in myself, I
system they are trapped in. Most clients know they are       wouldn’t be so anxious in new social situations.” The
suffering, but are completely immersed in the private        goal of therapy is to provide me with more confidence,
logic of their verbal conditioning. To attack this basic     so my anxiety will go away. The notion of “workabil-
problem, ACT tries to engender a healthy skepticism          ity” is central to ACT. Generally, clients have tried
about the role of language and thought in managing           these commonsense change strategies repeatedly, even
negative personal content. Ironically, therapy is an en-     in the face of repeated disconfirming experience (the
terprise that occurs within the context of the verbal        more you try to get confidence, the less confident you
community. To attempt to undermine dysfunctional             are). The client’s rule following has all but eliminated
rule-governed behaviors through the use of verbal            the corrective effects of direct experience. The client
concepts such as “belief,” “understanding,” and “in-         tries the same strategies over and over again, even
sight” is analogous to fighting a small fire with a can of     though direct experience suggests these strategies are
gasoline. The ACT therapist must use words, images,          doomed to fail. In ACT, the therapist is likely to ask,
metaphors, and experiential exercises in ways that un-       “Which are you going to believe here? Your mind or
dermine the client’s confidence in the utility of lan-        your experience?” Often, the clinical goal of this stage
guage and thought. This must occur without ACT               is simply to get the client to stop using strategies that
concepts being coopted into the client’s system of “un-      are not workable. At the same time, the therapist is at-
derstanding.” It is not unusual for an ACT therapist to      tempting to create a readiness to see the problem in a
say such things as, “If this makes sense, then that’s not    larger context.
it” or “Don’t believe a word I’m saying.” By attacking
the hegemony of language and thought through the                        B. Second Thematic Stage:
nonliteral use of verbal concepts, the therapist is fight-
                                                                         Control Is the Problem,
ing fire with fire. The trick is to avoid being burned.
   ACT can be separated into basic thematic compo-
                                                                             Not the Solution
nents that often occur in a somewhat predictable se-            In this thematic module, the client is exposed to the
quence. However, it is important to understand that          unworkable, paradoxical nature of control and elimina-
the relative prominence of different themes drives           tion strategies and their natural offshoot, experiential
both the focus and strategies of therapy. It is fre-         avoidance. The client is exposed via metaphor, story, and
quently unnecessary to expose a client to all the            experiential exercise to an essential feature of control and
stages of ACT. Some clients already have applied ex-         elimination strategies: The more one attempts to control
perience with acceptance and mindfulness strategies          undesirable content, the more undesirable content oc-
and may readily employ them when supplied with               curs. The rule of mental events, described earlier, is a cor-
the proper framework. However, the same client               nerstone of this stage. In this stage, the negative effects of
might struggle mightily with committed, valued ac-           experiential avoidance are drawn out for the client. Gen-
tions. With this type of client, more focus would be         erally, this involves determining what situations and/or
placed on values clarification, distinguishing life          experiences the client is avoiding in the service of con-
processes from life outcomes and so forth. For pres-         trolling negative experiences. Next, the client will evalu-
ent purposes, we shall describe the core themes as           ate whether the avoidance is “paying off” in terms of
“stages,” because there is a sort of logic to how            promoting positive psychological events or reducing
6                                            Acceptance and Commitment Therapy

negative ones. For example, the sexually abused woman                    D. Fourth Thematic Stage:
might be asked to gauge whether avoiding dating has in-                Self as Content, Self as Context
creased or decreased her sense of mistrust of men, in-
creased or decreased her sense of relationship failure, and        Acceptance is most likely to occur when there is an
so on. Generally, the concept of “willingness” will be in-      unassailable point from which to observe and make
troduced, as an alternative to control, elimination, and        room for distressing private content. Similar to various
avoidance. Willingness is the choice to have unpleasant         forms of meditation, ACT seeks to help the client lo-
private content at the level of awareness, but without          cate a sense of self that is larger than the experience of
evaluation or struggle. Often, clients will be asked to         the products of brain behavior. This is done in the serv-
maintain a “willingness-suffering-workability” diary that       ice of making willingness and various forms of accept-
lets them collect data on the relationship between levels       ance less emotionally hazardous for the client. In ACT,
of willingness, intensity of suffering, and perceived work-     there are three types of self: (1) Self as conceptualized
ability of their lives.                                         content is analogous to a “self concept.” It is the ver-
                                                                bally evaluated summary statement of characteristics
                                                                and attributes (i.e., I have always hated fighting). This
          C. Third Thematic Stage:                              form of self is quite rigid and is frequently a problem in
          Defusing Cognitive Fusion                             therapy. Many clients will vigorously defend their “self
   The Latin root of fusion means to “pour together.”           concept,” as if their life depended on it, even when the
As discussed earlier, clients suffer when they pour to-         content of the self-concept is negative; (2) Self as ongo-
gether direct experience, representations of direct             ing process reflects the ability to report current mood
experience, thoughts, feelings, and so forth. They be-          states, thoughts, verbal analyses, and other products of
come lost in the maze of private events, such that it be-       direct experience. This form of self is necessary for psy-
comes difficult to separate what is real from what is            chological health. It is the vehicle for experiencing
being represented. The goal of this stage is to help the        what is to be experienced in the “here and now.” Avoid-
client detach from the literal meaning of private expe-         ance of this form of self tends to produce the most basic
riences and instead to see private experiences as sepa-         and severe forms of psychopathology; (3) Self as con-
rate from the basic self. This goal is critical because it is   text is the most basic sense of self that is possible. It is
very difficult for clients to accept the most provocative,       awareness and consciousness itself. There are no limits
negative forms of private experience without the abil-          or boundaries to basic consciousness. It contains every-
ity to see private experiences from the perspective of          thing within it. It is immutable and, unlike other forms
an observer. ACT employs a wide variety of “deliteral-          of self, never changes in character. It is the context in
ization” strategies in this stage. Deliteralization strate-     which all private events take on reference. Whatever
gies generally seek to reveal the functional and/or             their form or content, the client’s struggles are acted
representational properties of language, stripped of            out on the stage of consciousness itself. Yet, the in-
their concealment in the system of language. This al-           tegrity of consciousness is not at issue. If accessed, this
lows the client to see thoughts as thoughts, feelings as        space puts the client in a position where private experi-
feelings, reasons as reasons, evaluations as evaluations,       ences can be observed, without struggle. In ACT, this is
and so forth. The result is that the client is able to de-      referred to as the “you that you call you.” Learning to
fuse fusion. This might involve showing how easily be-          make contact with this form of self is a skill that can be
havior can be programmed through simple, obvious                learned with practice. Consequently, ACT employs a
augmentation strategies. Alternatively, the client might        wide diversity of mindfulness, awareness, and medita-
be asked to produce multiple, different autobiogra-             tion exercises to develop this connection.
phies or to say the word “milk” over and over again
until the word “goes away” and a gutteral, chopping                      E. Fifth Thematic Stage:
sound is all that is experienced. Throughout this stage,
                                                                      Willingness as a Chosen Action
clients are exposed to the FEAR algorithim, as it is ex-
pressed through cognitive fusion. A host of metaphors,             Given the conditioned, rule-governed nature of pri-
stories, and experiential exercises are typically em-           vate experience, little direct control can be exerted
ployed to attack the literal attachment to cognition,           over the instantaneous reactions triggered by various
emotion, memory, and other private representations              stimulus events. In a previously described stage of
of experience.                                                  ACT, willingness is used to describe a nonjudgmental
                                             Acceptance and Commitment Therapy                                           7
awareness of disturbing private content. However,               is, “What do you want to be remembered for, by those
there is a more basic form of willingness that is central       you leave behind?”
to ACT. Willingness the action is the choice to enter              There are many nuances involved in developing com-
into valued life activities, with certain knowledge that        mitted action. One is helping the client differentiate be-
feared, private responses will be stimulated. These             tween values as process rather than values as outcomes.
“monsters” generally are associated with the control,           To this end, ACT employs a variety of exercises that em-
elimination, and avoidance behaviors that have previ-           phasize committed action as a journey, rather than a des-
ously trapped the client. This form of willingness is a         tination. A basic ACT principle is, “Goals are the process
qualitative act, driven by choice, rather than by per-          by which the process becomes the goal.” Vitality is pro-
suasion or reason.                                              duced by seeking, rather than by reaching valued out-
   Choice is a core concept in ACT. It is an action taken       comes. Further, some values cannot be “achieved,” only
with reasons, but not for reasons. It is a form of volun-       enacted on a continuing chosen basis. An example is the
teerism, or voting with one’s feet. This is the resting po-     value of being a loving spouse. One never “reaches”
tential of any client; the ability to transcend learning,       love; there is always more love to experience. Similarly, a
history, and logic and simply take an action that can           loving act often occurs when the feeling of love is miss-
produce vitality, meaning, and purpose. A variety of            ing. A second issue is that, in the name of seeking vital-
ACT exercises teach the client that willingness is both a       ity, the client may have to jettison a well-practiced story
chosen action and almost invariably involves making             that rationalizes why vitality and meaning are impossi-
room for feared experiences. Choosing willingness is            ble to attain. Frequently, this story involves traumatic
made more difficult when cognitive fusion is extreme             personal history and the need to remain dysfunctional
and the sense of self as context is weak. Thus, willing-        to prove that a transgression occurred. The client may
ness and choice generally become therapeutic foci               have to let go of the sense of trauma, shame, and blame
when cognitive defusion and self-identification strate-          in order to pursue vitality. In ACT, this form of forgive-
gies have had some degree of success. In the sexual             ness is construed to mean, “Giving oneself the grace that
abuse example, the willingness question might be,               came before the transgression.” A common ACT ques-
“Would you be willing to continue dating in the service         tion is, “Who would be made right, or who would have
of your dreams of developing intimacy, knowing that             to be let off the hook of blame, if you committed your-
you will have to make room for mistrust, conditioned            self to living a valued life?”
fear responses, and self critical thoughts?”

            F. Sixth Thematic Stage:                                  III. EMPIRICAL STUDIES OF ACT
               Values, Goals, and
                                                                   ACT is a relative newcomer to the family of cogni-
                Committed Action
                                                                tive-behavioral treatments and therefore does not have
   Although ACT is heavily focused on dismantling in-           a highly developed empirical literature at this point.
effective rule-governed behaviors, this process is impor-       However, the initial empirical results have been posi-
tant only to the extent that it results in the client living    tive. There have been two controlled studies looking at
a more vital, purposeful life. This can only be achieved        the relative efficacy of ACT and cognitive therapy with
through committed actions that are in pursuit of valued         depressed patients. In one controlled study, ACT pro-
life outcomes. Often clients have lost sight of their           duced significantly greater reductions in depression
dreams, because of the pernicious effects of control and        than cognitive therapy. A second controlled study with
avoidance behaviors. They have slipped into a haze              depressed patients showed the two treatments to have
where it is difficult to imagine a life much different from      equal efficacy. However, analysis of depressive thinking
the one they are living. ACT attempts to “jump start”           process measures suggested that ACT had a signifi-
the process of committed action by helping the client           cantly greater impact in reducing the believability of
define core life values, associated goals and develop spe-       depressive thoughts. A recent study examined the ef-
cific committed actions. A basic ACT intervention is             fect of providing a psychoeducational intervention or
called, “What do you want your life to stand for?” This         ACT with a randomly assigned group of hospitalized
involves having the client imagine that he or she has           patients with schizophrenia. The interventions were
died and is listening to eulogies from different signifi-        designed to target the disturbing effects of visual and
cant others at the funeral. The question to be answered         auditory hallucinations. Results were intriguing: ACT
8                                           Acceptance and Commitment Therapy

patients reported a greater self-reported frequency of         traction. Rule-governed responses never really disappear,
hallucinations, but rated the hallucinations as less           they are simply placed in a different relational frame
distressing than the psychoeducational intervention            under the dominance of new rule-governed behaviors.
patients. In contrast, the patients undergoing psychoe-        When ACT is successful, clients understand that there is
ducational treatment reported significantly fewer hallu-        no need to shun undesirable personal history, tempera-
cinations, but significantly more distress associated           ment, spontaneous emotions, thoughts, and so forth.
with the hallucinations. ACT interventions have also           These are unique and healthy human qualities. Indeed,
been shown to have a significant effect with such di-           the human organism is perfectly made to experience each
verse problems as chronic pain, occupational stress,           of these qualities, and therein lies the potential for vitality,
and high medical utilization.                                  purpose, and meaning.
   ACT is one of the few cognitive-behavioral treat-
ments to undergo a field-based clinical effectiveness
study. Strosahl and colleagues developed an ACT train-                See Also the Following Articles
ing package for a group of masters’ level therapists in        Avoidance Training I Language in Psychotherapy        I
an outpatient HMO mental health system. Compared               Relational Psychoanalysis
with a control group of therapists who did not receive
the training, ACT therapists produced greater clinical
benefits as reported by patients, had less referrals for                           Further Reading
psychiatric medicines, and were more likely to com-            Hayes, S. (1987). A contextual approach to therapeutic change.
plete cases earlier with the mutual consent of the                In N. Jacobson (Ed.), Psychotherapists in clinical practice:
client. In an uncontrolled clinical effectiveness study,          Cognitive and behavioral perspectives (pp. 327–387). New
Strosahl found that chronically depressed personality-            York: Guilford Press.
disordered patients treated in the ACT model reported          Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Rela-
significant reductions in depression and an increased              tional frame theory: A post-Skinnerian account of language
rate of achieving important personal goals. There are             and cognition. New York: Plenum.
several large clinical trials underway examining the ef-       Hayes, S., & Hayes, L. (1992). Understanding verbal relations.
                                                                  Reno, NV: Context Press.
fectiveness of ACT with severe drug addiction, tobacco
                                                               Hayes, S., Jacobson, N., Follette, V., & Dougher, M. (1994).
cessation, and social phobia. Hopefully, results of these         Acceptance and change: Content and context in psychother-
and future studies will help delineate the clinical effec-        apy. Reno, NV: Context Press.
tiveness of ACT, as well as describe the process mecha-        Hayes, S., Strosahl, K., & Wilson, K. (1999). Acceptance and
nisms that underpin the treatment.                                commitment therapy: An experiential approach to behavior
                                                                  change. New York: Guilford Press.
                                                               Hayes, S., Wilson, K., Gifford, E., Follette, V., & Strosahl, K.
                   IV. SUMMARY                                    (1996). Emotional avoidance and behavior disorders: A
                                                                  functional dimensional approach to diagnosis and treat-
   Acceptance and commitment therapy is one of the new            ment. Journal of Consulting and Clinical Psychology, 64,
generation of cognitive and behavioral therapies that uti-        1152–1168.
                                                               Strosahl, K. (1991). Cognitive and behavioral treatment of
lizes acceptance and mindfulness strategies, in addition
                                                                  the personality disordered patient. In C. Austad & B.
to first-order change strategies. The emphasis on accept-          Berman (Eds.), Psychotherapy in managed health care: The
ance strategies may be attributed to the growing recogni-         optimal use of time and resources. Washington DC: Ameri-
tion that first-order change is not always possible, or even       can Psychological Association.
desirable. There are many aspects of human experience                                                             .
                                                               Strosahl, K., Hayes, S., Bergan, J., & Romano, P (1998). As-
that cannot be directly altered through psychotherapy or          sessing the field effectiveness of acceptance and commit-
any other type of change effort. As we have discussed, the        ment therapy: An example of the manipulated training
human nervous system works by addition, not by sub-               research method. Behavior Therapy, 29, 35–64.
                                 Addictions in Special
                                Populations: Treatment
                                      Paul R. Stasiewicz and Kellie E. Smith
                                                    Research Institute on Addictions




    I.   Introduction                                                   nicity, gender, and health status. This article focuses on
   II.   Racial/Ethnic Minorities                                       the treatment of addictive behavior in racial/ethnic mi-
  III.   Women                                                          norities and women. These groups present unique
  IV.    Summary                                                        treatment issues such as pregnancy and culture-specific
         Further Reading
                                                                        beliefs and attitudes regarding substance use. In addi-
                                                                        tion members of minority groups report higher rates of
                                                                        substance abuse problems than do whites, and the
                            GLOSSARY                                    number of women entering treatment for substance
                                                                        abuse problems has increased in the past two decades.
cultural competence The belief that treatment providers
   should recognize and respect other cultural groups and be
   able to effectively work with them in a clinical setting.
special populations People with special treatment needs re-                  II. RACIAL/ETHNIC MINORITIES
   lated to age, gender, ethnic background, or health status that
   are underserved by alcohol and drug treatment resources.                      A. Description of Treatment
                                                                           Ethnic and racial diversity is increasing in the United
                                                                        States, and according to the 1991–1993 National
                     I. INTRODUCTION                                    Household Survey on Drug Abuse members of various
                                                                        ethnic minorities report higher rates of substance use
   The origin of the term “special population” can be                   and related problems than do Whites. Although a need
attributed to several U.S. government agencies in-                      for treatment services exists, special populations often
volved in health and human services in the mid-1970s.                   encounter barriers to obtaining treatment for alcohol
The term is reserved for groups whose need for sub-                     and drug problems. The Office for Substance Abuse
stance abuse treatment programs has been under-                         Prevention includes the following common barriers to
served. The purpose was to identify subgroups in order                  treatment:
to help with planning and evaluating the national treat-
ment system for alcohol and drug problems. The goal                        • Cultural barriers: Many programs lack staff who
was to provide funding for specialty programs, or to en-                share the cultural background of those being treated. In
sure that mainstream programs were structured to pro-                   addition, staff may lack sensitivity and/or training re-
vide appropriate treatment services. Special population                 garding the cultural beliefs and practices of their clien-
groups are most often defined in terms of age, race/eth-                 tele. Language barriers also may exist.


Encyclopedia of Psychotherapy                                                                       Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                            9                                                   All rights reserved.
10                                     Addictions in Special Populations: Treatment

    • Funding: Many members of minority groups lack             variability. Alternatively, it would not be realistic nor
insurance or personal funds to pay for treatment.               cost effective to develop separate programs for each
    • Availability: Waiting lists are common at afford-         distinct subgroup. This is not to say that the develop-
able programs.                                                  ment and cross-cultural validation of such programs be
    • Child care: Often not available at treatment sites.       discontinued. However, while these programs are being
Some people may fear losing custody of their children           developed and evaluated, it seems reasonable to utilize
if they seek treatment for an alcohol or drug problem.          existing approaches that have been demonstrated to
                                                                have relative efficacy with other populations of sub-
   These factors make it less likely that minorities will       stance abusers. Such treatment approaches include, but
enter mainstream treatment programs. Of those who do            are not limited to, brief motivational interventions,
enter treatment, the outcome data are mixed with some           cognitive-behavioral approaches, behavioral couples
studies showing minority patients to have treatment             therapy, and the community reinforcement plus vouch-
outcomes equal to those for Whites, and other studies           ers approach.
showing that minority patients have poorer outcomes
and are less likely to complete treatment.                      1. Brief Motivational Interventions
   The high rates of substance use problems among                  Brief interventions (e.g., motivational enhancement
many ethnic and racial minorities, combined with the            therapy, guided self-change) have been shown to be as
barriers encountered by these individuals in mainstream         effective as long-term inpatient treatment for alcohol
treatment programs, raise the issue of whether or not to        problems. Core elements of these interventions include
develop culturally sensitive treatment programs. Typi-          objective feedback regarding the nature and severity of
cally, these programs employ staff from varied cultural         the problem, acceptance of personal responsibility for
backgrounds and/or provide training to staff members in         change, providing a menu of change strategies, and an
cultural issues. Culturally sensitive treatment programs        empathic therapist style.
may improve access to treatment for some individuals,
but there are few scientific studies that examine or sup-        2. Cognitive-Behavioral Approaches
port their ability to produce improved outcomes. There-           A set of strategies including social skills training, be-
fore, the benefits of such programs are not yet                  havioral self-control training, relapse prevention, and
thoroughly understood. Moreover, there is often consid-         cognitive therapy. Core elements often include as-
erable heterogeneity within specific ethnic or racial            sertiveness training, coping with high-risk alcohol and
groups. Major sources of such heterogeneity include             drug use situations, managing urges and cravings,
                                                                managing thoughts about drinking and drug use, prob-
   • Subgroups within a major ethnic group: For exam-           lem-solving training, drink and drug refusal skills, and
ple, there are approximately 300 different American In-         managing negative thinking and negative moods.
dian tribes. Many of these have their own unique
culture and have developed specific norms regarding              3. Behavioral Couples Therapy
substance use, help-seeking behavior, and healing.                 This approach aims to improve communication and
Similarly, Hispanics who are Cuban American, Central            conflict resolution skills to help achieve and maintain
American, Puerto Rican, and Mexican American have               abstinence. It assumes that family members can reward
different attitudes toward substance use and treatment          abstinence and that alcohol and drug abusers with
for substance-related problems.                                 healthier relationships have a lower risk of relapse. Ac-
   • Personal characteristics: Members of the same mi-          cording to Timothy O’Farrell and William Fals-Stewart
nority group vary on several dimensions that have im-           a core element of this approach is the daily sobriety con-
plications for treatment outcome. Included here are             tract in which the patient expresses his or her intention
socioeconomic status, education level, and employ-              not to drink or use drugs on a given day, and the spouse
ment status.                                                    provides support for efforts to remain abstinent.
   • Acculturation: Members of the same minority group
may differ in terms of their acculturation or assimila-         4. Community Reinforcement
tion to the majority culture.                                   Plus Vouchers Approach
                                                                  This approach includes a number of skills-training
  It is unlikely that a single treatment approach could         components similar to those mentioned earlier. It also
be developed that would suffice in addressing such               includes prompt reinforcement for drug abstinence by
                                        Addictions in Special Populations: Treatment                                   11
using vouchers. The points accumulated can be spent              the lack of theoretical development in this area, many
for anything that contributes to furthering the patient’s        accounts of substance abuse within a specific cultural
treatment goals. All purchases are made by the treat-            group may be explained by existing models of addictive
ment staff.                                                      behavior. For example, a popular cognitive-behavioral
   Given the absence of research on the application of           model of addictive behavior is the stress-coping model.
these and other treatment approaches for ethnic mi-              This model views substance use as a coping response to
norities, how should one proceed in tailoring existing           life stress that can function to reduce negative affect or
treatment approaches to culturally diverse groups? The           increase positive affect. Stress refers to the problems or
following steps have been proposed by clinicians and             tensions that people encounter throughout life, and
researchers alike. First, mainstream substance abuse             coping refers to the behavioral or cognitive responses
treatment programs can ensure a degree of cultural sen-          that people use to manage stress. Although the nature
sitivity by hiring minority staff and/or providing train-        of the stress may vary across cultures (e.g., PTSD
ing to increase the cultural responsiveness of staff             among Southeast Asians), the underlying mecha-
members. Although there is limited evidence to sup-              nism—that alcohol and drugs reduce stress—may gen-
port the overall treatment effectiveness of culturally           eralize from culture to culture.
sensitive therapists (CSTs), there is somewhat more ev-             High rates of substance abuse in some ethnic minori-
idence to support the role of CSTs in engaging and re-           ties have been attributed to relatively greater experi-
taining minorities in treatment. Second, it would be             ences of stress. Major sources of stress include
important to identify the unique cultural aspects of a
particular group, including those that may be affecting          • Environmental stressors: Several major stressors in-
the person’s recovery. For example, a client whose cul-            clude substandard housing, overcrowding, and un-
ture teaches her to be passive may feel it is wrong to ex-         safe living conditions.
press her feelings, even though such feelings may be a           • Social stressors: Factors included here are poverty,
reason for continued substance use. Third, existing                greater exposure and access to drugs, discrimina-
treatment approaches can be modified to include cul-                tion, and unemployment.
turally relevant material. Comas-Diaz and Duncan in-             • Personal stressors: A few examples include depres-
cluded a cultural component in an assertiveness                    sion, helplessness, and low self-esteem.
training program for low-income Puerto Rican women.
In addition to standard assertiveness training, the                 In addition to increased stress, ethnic minorities may
women identified cultural factors prohibiting the de-             lack the personal and social resources necessary to sup-
velopment and expression of assertive behavior. They             port effective coping responses. In the absence of good
also identified potential conflicts that might arise as a          coping skills individuals may use alcohol and other
result of their assertiveness and were taught strategies         drugs to cope with stress. The view that substance
for managing these conflicts.                                     abuse is a dysfunctional coping response to stress led to
   Although most writers call for culturally relevant            the development of psychosocial interventions focused
treatment, there are few models that operationally de-           on strengthening an individual’s coping skills. With re-
fine how clinicians and researchers should proceed.               gard to substance abuse treatment for minorities, the
Clearly, there is a need for the systematic development          objective for coping skills interventions is to incorpo-
and evaluation of such treatment programs. However,              rate culturally relevant content when addressing the
while waiting for such programs to be developed, on-             stressors unique to specific cultural groups.
going efforts should be made to adapt existing, empiri-             Acculturation theory has also been linked to sub-
cally supported treatments to specific cultural groups            stance abuse in ethnic minority groups. Briefly, this
and to enhance the cultural competence of therapists in          theory refers to the three phases of contact, conflict,
mainstream treatment programs.                                   and adaptation through which members of both minor-
                                                                 ity and majority cultures move, before assimilation is
                                                                 achieved. The ability to align equally with values, atti-
              B. Theoretical Bases
                                                                 tudes, and behaviors of both the minority and majority
  Theoretical models of substance abuse among ethnic             culture is called “bicultural competence.” With regard
minorities are lacking. Reasons for substance abuse are          to substance use, a person with a monocultural orienta-
more common and are typically based on one or more               tion is likely to experience more stress than a person
key characteristics of a given cultural group. Despite           with a bicultural orientation, and therefore is more
12                                       Addictions in Special Populations: Treatment

likely to use alcohol and other drugs to cope with the            cluding nutrition, hygiene, prenatal and postpartum
stress. In this way, acculturation theory is similar to the       care; vocational rehabilitation; legal assistance; trans-
stress and coping model described earlier.                        portation assistance; and access to female treatment
                                                                  providers. A consistent difference between women-ori-
                                                                  ented programs and mixed-gender programs is the pro-
             C. Treatment Outcome                                 vision of services associated with pregnancy and
   The focus in research has been on demographic and              parenting.
descriptive characteristics of substance abuse problems              Common treatment approaches for women include
among various cultural groups. Well-conducted treat-              cognitive-behavioral coping skills interventions, brief
ment outcome studies are lacking, so it is unknown                motivational interventions, family therapy, pharma-
whether outcomes would be improved if treatment pro-              cotherapy, and self-help groups. Within each of these
grams were more sensitive to cultural issues. Con-                approaches, women’s issues are addressed by the inclu-
trolled trials are needed in which the effectiveness of           sion of one or more of the women-oriented treatment
existing treatments for substance abuse problems are              components mentioned earlier.
compared with treatments specifically designed, or
modified, for a given cultural group. The main question            1. Cognitive-Behavioral Approaches
to be addressed is whether culturally relevant treatment             Women with alcohol problems exhibit poorer skills
approaches increase accessibility, retention, and out-            for coping with stressors than do women without alco-
come in ethnic minority populations.                              hol problems. Alcohol may be used as a primary coping
                                                                  behavior for these women. This treatment approach
                                                                  teaches skills for coping with high-risk alcohol and
                                                                  drug use situations and also provides other life man-
                    III. WOMEN
                                                                  agement skills (e.g., problem-solving, communication,
                                                                  assertiveness, and other skills).
         A. Description of Treatment
   In 1991, The National Institute of Mental Health Epi-          2. Brief Interventions
demiologic Catchment Area Study (ECA) reported that                 These interventions provide information, feedback,
substance abuse was the second most common psychi-                advice, and support and are known to be effective in
atric disorder among all female respondents. In addi-             addressing substance abuse problems. When the goal is
tion, the number of women entering treatment for                  drinking reduction, brief interventions for problem
substance abuse problems has increased by approxi-                drinking have been shown to be more effective among
mately 10% since the late 1980s. Despite this increase,           women than among men.
Yaffee and colleagues assert that the special needs of
women remain unmet by the majority of mainstream                  3. Family Therapy
treatment programs. In fact, it has been argued that                Strategic-structural family therapy and behavioral
mainstream treatment programs may be seen as a bar-               family therapy are the two most frequently used models
rier to women seeking treatment for substance abuse               of family therapy for the treatment of substance-de-
problems. For example, the lack of on-site child care             pendent women. Family therapy is seen as beneficial
services may limit access to treatment for many women.            because family members often play a significant role in
   In the past two decades, funding has increased to aid          the etiology and maintenance of problematic patterns
the development of treatment programs specifically de-             of substance use among women. For example, a
signed for substance-abusing women. These women-                  woman’s drinking pattern is often influenced by her
oriented treatment programs are characterized by an               male partner’s pattern of drinking. Therefore, it may be
emphasis on understanding the importance of gender                helpful to include both individuals in treatment.
roles in society and how these roles may contribute to
the development and maintenance of substance abuse                4. Pharmacotherapy
problems in women. Important components of women-                    Compared to men, women report more psychiatric
oriented treatment programs include the following:                problems and are more likely to drink to relieve nega-
treatment for other problems (e.g., domestic violence,            tive affect. In this regard, medications may be used as
depression); child care services; parenting and family-           adjuncts to psychosocial treatment for substance use
oriented services; comprehensive medical services in-             and psychiatric disorders. Disulfiram (Antabuse) has a
                                       Addictions in Special Populations: Treatment                                  13
long history of use as deterrent medication. When               treatment programs generally include a range of serv-
taken with alcohol it produces nausea, vomiting, dizzi-         ices and develop treatment plans in which specific serv-
ness, difficulty breathing, headache, flushing, and rapid         ices are matched to the needs of the individual patient.
heartbeat. Disulfiram is administered orally on a daily
basis, and the client cannot drink for 4 to 7 days fol-
                                                                              C. Treatment Outcome
lowing discontinuation of the medication. This delay
often provides the individual with time to reconsider              When examining outcome data from mixed-gender
the decision to begin drinking. Naltrexone (Revia) is an        programs, studies to date have found few differences in
orally administered opioid antagonist that more re-             treatment outcome for men and women. In contrast, re-
cently has been found to be effective for the treatment         search investigating the effectiveness of women-oriented
of alcohol problems. It has been found to decrease              treatment programs has produced mixed findings. Some
craving for alcohol and to produce lower relapse rates          studies demonstrate better outcomes for women in
when added to psychosocial treatment for alcoholism.            women-oriented programs compared with women
Antidepressants and other psychotropic medications              treated in mainstream programs, and others report no
may be used to help treat a range of psychiatric symp-          differences. A study by Dahlgren and Willander com-
toms that serve to maintain the substance use disorder.         pared women in a women-oriented program (n = 100)
                                                                with female patients in a mainstream program (n = 100).
5. Self-Help Groups                                             At the 2-year follow-up, patients in the women-oriented
   In addition to Alcoholics Anonymous, Women for               treatment program had better outcomes both in terms of
Sobriety is a mutual-help organization designed to              alcohol consumption and social adjustment as measured
meet the specific needs of women. The program con-               by employment status and family relationships.
sists of 13 statements, primarily focused on improving             With regard to the effectiveness of specific interven-
self-worth and reducing shame and guilt often reported          tions for women, research has demonstrated that drink-
by its members. Self-help groups can be very useful             ing reduction interventions appear to be beneficial for
treatment approaches because they provide an excel-             women who are less physically dependent on alcohol.
lent opportunity for women to develop new social roles          Several studies have demonstrated that women problem
and relationships and to construct a non-substance-             drinkers were more successful than men in attaining
abusing support network.                                        moderate drinking. Cognitive-behavioral interventions,
   The treatment approaches just summarized are only            in which patients are matched on the basis of personal-
a few examples of the wide range of treatment options           ity characteristics and level of motivation, have shown
available. Because a large number of substance-abusing          benefit with female substance abusers. Brief interven-
women have multiple problems, there is a need to pro-           tions that incorporate motivational interviewing strate-
vide broad and comprehensive services for women. For            gies have also been effective in reducing alcohol
example, a cognitive-behavioral treatment program for           consumption for problem-drinking women. Finally,
women with alcohol problems may be combined with                some studies have indicated that women benefit from
pharmacotherapy to address strong cravings for alcohol          self-help groups, such as Alcoholics Anonymous and
or symptoms of depression. In addition, existing treat-         Women for Sobriety. It is thought that women do well in
ment approaches may be further modified to address               these groups because they become more involved in the
the individual needs of each female patient (e.g., prena-       social support network offered by this type of treatment.
tal care).                                                         Although it appears that women do benefit from
                                                                treatment, well-conducted treatment outcome studies
                                                                are lacking, so it is unknown whether outcomes would
              B. Theoretical Bases
                                                                be improved if treatment programs were more sensitive
   Most of the work regarding substance abuse in                to gender issues. Nevertheless, one advantage of
women is largely atheoretical. However, social relation-        women-only treatment programs may be their ability to
ships have been reported to play a greater role in the          attract women who would not otherwise have sought
psychological development of women as compared                  treatment from a mainstream program. For example, a
with men. In this regard, interventions that focus on           study by Copeland and Hall found that clients enrolled
the development of new relationships or that                    in a women’s treatment program were more likely to be
strengthen the woman’s social support network are               lesbian, or have suffered childhood sexual abuse than
viewed as beneficial. However, most women-oriented               women enrolled in other programs. Therefore, the
14                                        Addictions in Special Populations: Treatment

availability of women-oriented programs and services               Copeland, J., & Hall, W. (1992). A comparison of women
may contribute to reducing barriers to treatment for                  seeking drug and alcohol treatment in a specialist women’s
some women.                                                           and two traditional mixed-sex treatment services. British
                                                                      Journal of Addiction, 87, 1293–1302.
                                                                   Helzer, J. E., & Pryzbeck, T. R. (1988). The co-occurrence of
                                                                      alcoholism with other psychiatric disorders in the general
                   IV. SUMMARY                                        population and its impact on treatment. Journal of Studies
                                                                      on Alcohol, 49, 219–224.
   In 1990, an Institute of Medicine report suggested that         Institute of Medicine. (1990). Broadening the base of treatment
caution must be exercised when defining a given person                 for alcohol problems. Washington, DC: National Academy
only in terms of his or her gender or racial/ethnic group             Press.
membership; individuals within both of these special               Lisansky Gomberg, E. S., & Nirenberg, T. D. (1993). Women
populations vary on other important dimensions that                   and Substance Abuse. Norwood, NJ: Ablex.
have implications for treatment entry and outcome (e.g.,           Miller, J. B. (1984). Toward a New Psychology of Women (2nd
socioeconomic level, education). Moreover, the hetero-                ed.). Boston: Beacon.
geneity among persons with substance abuse problems                National Institute on Alcohol Abuse and Alcoholism. (1994).
                                                                      Special focus: Women and alcohol. Alcohol Health and Re-
suggests that it may be difficult to identify the key char-
                                                                      search World, 18, (3).
acteristic to use in determining a treatment referral. For
                                                                   O’Farrell, T. J., & Fals-Stewart, W. (2000). Behavioral couples
example, an individual can be a member of more than                   therapy for alcoholism and drug abuse. Journal of Sub-
one special population group (e.g., a married, black fe-              stance Abuse Treatment, 18, 51–54.
male with depression). In this case, how does the clini-           Office for Substance Abuse Prevention. (1990). Alcohol and
cian decide which special program best meets the need                 other drug use is a special concern for African American
of this client? At present, the answer is not clear. How-             families and communities (OSAP Fact Sheet, Appendix C).
ever, Copeland and Hall and others have reported that                 In U. J. Oyemade & D. Brandon-Monye (Eds.), Ecology of
special programs may be more likely to attract individu-              alcohol and other drug use: Helping black high-risk youth
als who would not otherwise seek treatment.                           (OSAP Prevention Monograph-7). Rockville, MD: U.S. De-
                                                                      partment of Health and Human Services, Alcohol, Drug
                                                                      Abuse, and Mental Health Administration.
       See Also the Following Articles                             Pagliaro, A. M., & Pagliaro, L. A. (Eds.). (2000). Substance
                                                                      use among women: A reference and resource guide. Philadel-
Controlled Drinking I Cultural Issues I Matching                      phia, Pennsylvania: Taylor & Francis Group.
Patients to Alcoholism Treatment I Multicultural Therapy           Rebach, H. (1992). Alcohol and drug use among american
I Race and Human Diversity I Substance Dependence:
                                                                      minorities. In J. E. Trimble, C. S. Bolek, & S. J. Niemcryk
Psychotherapy I Transcultural Psychotherapy                           (Eds.), Ethnic and multicultural drug abuse: Perspective on
                                                                      current research (pp. 23–57). New York: Haworth.
                                                                   Substance Abuse and Mental Health Services Administration.
                  Further Reading
                                                                      (1998). Prevalence of substance use among racial and ethnic
Caetano, R., Clark, C. L., & Tam, T. (1998). Alcohol con-             subgroups in the United States: 1991–1993. Available from
  sumption among racial/ethnic minorities. Alcohol Health             http://www.samhsa.gov/oas/oas.html
  and Research World, 22, 233–241.                                 Terrell, M. D. (1993). Ethnocultural factors and substance
Center for Substance Abuse Treatment. (1994). Practical ap-           abuse: Toward culturally sensitive treatment models. Psy-
  proaches in the treatment of women who abuse alcohol and            chology of Addictive Behaviors, 7, 162–167.
  other drugs. Rockville, MD: U.S. Department of Health and        Wetherington, C. L., & Roman, A. B. (Eds.) (1998). Drug addic-
  Human Services, Public Health Services.                             tion research and the health of women. Rockville, MD: NIDA.
Comas-Diaz, L., & Duncan, J. W. (1985). The cultural context:      Yaffe, J., Jenson, J. M., & Howard, M. O. (1995). Women and
  A factor in assertiveness training with mainland Puerto             substance abuse: Implications for treatment. Alcohol Treat-
  Rican women. Psychology of Women Quarterly, 9, 463–47.              ment Quarterly, 13, 1.
                    Adjunctive/Conjoint Therapies
                                                        Robert Ostroff
                                                  Yale University School of Medicine




    I.   Adjunctive/Conjoint Therapy                                    split treatment The practices of separating treatment func-
   II.   Theoretical Basis                                                 tions into different domains. Most often this treatment is
  III.   Historical Overview                                               used in long-term hospital settings to address the split
  IV.    Summary                                                           between administrative and therapeutic functions.
         Further Reading

                                                                                  I. ADJUNCTIVE/CONJOINT
                            GLOSSARY                                                      THERAPY
adjunctive therapy Two or more therapies used in an integra-               In today’s psychological treatment setting, it is com-
   tive fashion to treat an individual with mental illness.             mon to find two or more treatments being used to-
conjoint therapy Therapy consisting of two distinct treat-              gether by different health care providers to treat the
   ment models: (1) The treatment of two or more related in-            same patient. In fact, with today’s emphasis on out-
   dividuals in the same setting, for example, couples treated
                                                                        come and results rather than on the process orientation
   in a group therapy or family therapy groups and (2) treat-
   ment used interchangeably with adjunctive therapy. In this
                                                                        that dominated the treatment environment until the
   chapter, the second meaning always applies.                          last several decades, it is more common than not to find
integrative treatment Treatment that attempts to theoreti-              adjunctive therapy as the dominant treatment interven-
   cally reconcile different therapeutic approaches into a sin-         tion. Although the varieties of adjunctive therapeutic
   gle therapeutic approach, for example, psychodynamic                 interventions are too numerous to catalog, they may be
   and behavioral. May also be used interchangeably with ad-            broken down into several common combinations. By
   junctive therapy.                                                    far the most common form of this treatment today is
psychopharmacotherapy The use of medication to treat men-               the use of psychopharmacotherapy and individual psy-
   tal illness. This therapy is performed primarily by a psychi-        chotherapy. In addition, individual therapies are often
   atrist but may also be practiced by primary care physicians,         used adjunctively with group therapy and/or family
   physician assistants, and advanced nurse practitioners.
                                                                        therapy.
sociotherapy The consideration of the patient’s entire social
   milieu as an agent of therapeutic treatment. This treat-
                                                                           As treatment has become more focused and refined,
   ment is most often practiced in a hospital setting but may           specialized programs are increasingly being used to
   also be used in residential settings of all types, including         treat individuals with similar disorders. Consequently,
   group homes and specialized treatment facilities (e.g.,              12-step substance abuse groups are used with individual
   substance abuse programs or other psychiatric rehabilita-            substance abuse counseling, and dialectical behavioral
   tive settings).                                                      therapy (DBT) training groups are used adjunctively


Encyclopedia of Psychotherapy                                                                        Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                           15                                                    All rights reserved.
16                                            Adjunctive/Conjoint Therapies

with individual DBT treatment and diagnostically fo-                          A. Treatment Hierarchy
cused groups. For example, anxiety disorder groups
or obsessive-compulsive groups are used adjunctively              The treatment hierarchy in adjunctive therapy is per-
with cognitive-behavioral therapy. Each type of ad-            haps the most straightforward, and because it involves
junctive therapy may involve slightly or even radically        power, it is also the most difficult area for therapists to
different theoretical biases on the part of individual         address. There is a twofold need to identify a primary
therapists. A substance abuse counselor running a 12-          or principal therapist in any adjunctive therapy: the
step group will be informed by a different theoretical         need of the patient to know who is in charge of the
orientation than a psychodynamic psychotherapist.              treatment and coordinating it and the need of the ther-
The DBT therapist may operate from a different orien-          apists involved to know who is responsible for the co-
tation than a psychopharmacotherapist. Yet, with ad-           ordination and integration of care.
junctive therapy, the often varying viewpoints of the             Typically, the patient identifies the principal thera-
treaters are not only made to work together but also           pist as the one he or she first contacts when initiating
often produce results that are superior to either treat-       treatment. If a patient sees an individual therapist for
ment alone. Regardless of the type of adjunctive ther-         several sessions and the decision is made to seek a psy-
apy, a common set of issues arise whenever conjoint            chopharmacotherapy consultation, the patient will in-
treatment occurs.                                              variably regard the individual therapist as the principal
   Whenever more than one therapist is involved in             therapist. The patient is likely to orient toward the in-
                                                               dividual therapist in seeking to identify who the psy-
the treatment of the same patient, the issues that al-
                                                               chopharmacotherapist is and later in processing
ways give structure to the treatment are the following:
                                                               recommendations made by the psychopharmacothera-
(1) Treatment hierarchy: Most typically this involves
                                                               pist. The converse is just as often true when the psy-
the identification of a primary therapist. (2) Role defi-
                                                               chopharmacotherapist is seen initially in consultation.
nition: The function of each therapist needs to be
                                                               When the need arises for adjunctive therapy with a re-
clearly defined, his or her primary domain delineated,
                                                               ferral to an individual therapist, the patient is likely to
and there must be a clear understanding of when each
                                                               regard the psychopharmacotherapist as the principal
therapist would intervene and when a referral would
                                                               therapist. This hierarchical structure implicitly in-
be made to another therapist. (3) Theoretical clarity:
                                                               volves power because the patient will regard the princi-
Each therapist must understand the theoretical per-            pal therapist as being the arbitrator for decisions
spective of not only his or her own treatment modal-           regarding treatment and, in fact, as the person who is
ity but also that of all others involved in the treatment      “in charge” of the treatment. For example, if the need
of the patient. It is also imperative for each therapist       arises for hospitalization, the patient will look to the
to understand areas of potential conflict between the-         principal therapist for a recommendation. In this case,
oretical orientations and areas where the treatments           if the individual therapist is a nonphysician and the
should be complementary. (4) Boundaries: The                   psychopharmacotherapist is a physician, the patient
boundaries or parameters for each therapy need to be           may look to the individual therapist for guidance, even
defined clearly for the patient, but each therapist            though the physician is the therapist with the power to
should also understand the boundary definitions of all         hospitalize.
the therapists involved in an adjunctive therapy. (5)             It is crucial that the treaters understand this hierar-
Goals: Goals, or expected treatment outcome, should            chy because these power issues relate directly to the
be explicitly defined, for each therapist may have a           therapist’s professional identity. Each discipline that de-
different contribution to make to the outcome. (6)             fines the therapist’s professional identity comes with
Communication: Clear guidelines are needed for com-            explicit and implicit skill sets that define expertise and
munication between therapists that define when to              power. The physician therapist may feel that he or she
communicate and how much to communicate. These                 alone should have the power to make decisions regard-
six areas provide the structure for any type of adjunc-        ing hospitalization or medication changes. The psychol-
tive therapy regardless of what combination is being           ogist therapist treating an individual, who is in couple’s
used. Because psychopharmacotherapy individual                 treatment together with a social worker, may have diffi-
psychotherapy is currently the most common type of             culty with the social worker colleague recommending
adjunctive therapy, I will use it as a model to explicate      psychological testing. These discipline-specific sets of
each of these areas.                                           expertise and power need to be understood and should
                                               Adjunctive/Conjoint Therapies                                             17
be somewhat fluid to allow for successful adjunctive             pist about increasing dysphoria and may want to deal
therapy. Although it is true that the physician alone has       with it as an individual therapy issue. On another oc-
the power to prescribe a medication, the patient may            casion, the patient will seek the psychopharmacother-
not take the medication or comply with the physician’s          apist’s help with a medication that aids in improving
recommendation without the support and validation of            his or her relationship with female co-workers. In
the primary therapist, who might be a social worker. If         these instances, the therapist must be able to recognize
the treatment hierarchy is understood, it reduces the           the limits of his or her role and be comfortable direct-
potential for confusion on the patient’s part and lessens       ing the patient to the other therapist. Between the two
threats to the professional identity of the therapists in-      borders of the roles there is the need for each therapist
volved in the treatment.                                        to move in and out of the other’s domain. Although
   The principal therapist can change during the course         psychopharmacotherapy may seem to be easily con-
of a treatment but must make this change explicit and           fined to the biological realm, in practice this is rarely
coordinate it. One of the therapists involved in the            the case. Taking a medication can have powerful psy-
treatment may leave the area, necessitating a replace-          chological meaning for the patient and will need to be
ment, a therapist may have irreconcilable differences           discussed and dealt with by the individual therapist as
with a patient, or one of several therapeutic compo-            well as by the psychopharmacotherapist. On the other
nents of an adjunctive therapy may reach a termination          hand, socially phobic patients whose symptoms are re-
point. The principal therapist would coordinate ad-             lieved by medication may have to redefine themselves
dressing and resolving all of these issues.                     and examine how the change in a set of behaviors ne-
                                                                cessitated by the symptom that is now gone will affect
                                                                their personal identity. Clearly, this is the role of the
                B. Role Definition                               individual therapist.
   Adjunctive therapy involves two or more therapists              Some issues clearly involve both roles and need to be
intervening in different ways and often in different do-        addressed by both therapists. Insomnia is an example.
mains with the same patient. The roles of the therapists        In a patient with a mood disorder, insomnia might be
may vary widely, and their areas of intervention may            an early warning that medications need to be changed
overlap to varying degrees. The role of each therapist          or adjusted or that a relapse is beginning. Insomnia
needs to be clearly defined. Well-delineated roles aid all       may also mean that the patient is having difficulty man-
the therapists involved and diminish the potential for          aging external stressors and needs psychological help
patient noncompliance, acting out, or resistance to             in improving coping skills. It should be apparent that
treatment. Using individual therapy/psychopharma-               these are not mutually exclusive phenomena and could
cotherapy as a model adjunctive treatment illustrates           occur simultaneously, requiring interventions by both
both the difficulties and the need for role definition.           therapists. In fact, either therapist could perform an in-
   The individual therapist’s role is focused on the psy-       tervention such as instructing the patient about sleep
chological domain of the individual and is confined to           hygiene. This also highlights the need for communica-
effecting change in psychological processes. The psy-           tion among therapists, which will be addressed in a
chopharmacotherapist’s role is focused on the biologi-          later section.
cal domain of the individual and is confined to using               Role definition also must address practical adminis-
medications to effect physiological changes and lead to         trative issues, or else confusion and conflict may arise.
symptom relief, maintenance of a given state (e.g., eu-         Each therapist needs to know what the expectation of
thymic mood), or relapse prevention. This oversimpli-           the other therapist is during the course of treatment.
fication diminishes the role of both the treaters and the        Coverage issues also need to be clarified. Who fills in
effectiveness of the adjunctive therapy. At the far bor-        for therapists’ absences needs to be understood. In an
der of role definition, it is clear that the individual          adjunctive therapy it is often tempting for each thera-
therapist will not be making recommendations about              pist to cover for the other during vacations. This ap-
specific medications and the psychopharmacotherapist             proach can blur roles, causing confusion and leading
will not be making recommendations about interven-              to conflict. If the psychopharmacotherapist covers for
tions that need to be made in individual therapy. At the        the individual therapist and an emotional crisis occurs,
near border of role definition, there may be great over-         for example, he or she may need to temporarily take
lap. The patient will complain to the individual thera-         over the role of the therapist. Later, it may be difficult for
18                                             Adjunctive/Conjoint Therapies

the psychopharmacotherapist to revert to his role, and          medication following a medical model may approach a
it may prone confusing to the patient. Similarly, it            patient threatening suicide very differently. The DBT
must be clear whether the individual therapist is ex-           therapist may already have had an agreement with the
pected to monitor side effects and/or report them. This         patient that the patient go to an emergency room and
will directly affect the frequency of visits to both ther-      only contact the therapist when all danger had passed.
apists. It is obvious that gross side effects will be re-       The psychopharmacotherapist may feel the need to
ported, but obviously it is not the role of the individual      take an active role in the patient’s hospitalization and
therapist to perform screening tests examining for side         continue to treat the patient in a hospital setting. Only
effects. Depending on the nature of the individual              with an appreciation of the DBT therapist’s orientation
therapy it may have more or less of an impact on the            and of what he or she is attempting to achieve with the
therapist’s role.                                               patient can the psychopharmacotherapist intervene,
                                                                support the DBT therapist’s position, and encourage
                                                                the patient to return to the therapist when the danger
             C. Theoretical Clarity                             of suicide has passed.
   Adjunctive therapy often involves the collaboration             Before entering into an adjunctive therapy, each ther-
of therapists with different theoretical orientations.          apist should learn the theoretical orientation of the
For the most part, these theoretical orientations are           other therapist, understand areas of potential conflict,
not inherently conflictual, although they may vary in            and be certain that they can all work compatibly to-
emphasis. A behavioral therapy that focuses on chang-           gether without feeling devalued or devaluing. If this is
ing observable patterns of behavior or reported cogni-          not possible, it is best to avoid adjunctive therapy col-
tive patterns does not conflict with a dynamically               laboration.
oriented couples therapy that views behavior as arising
out of early family patterns and roles. If, simultane-                             D. Boundaries
ously, a psychopharmacotherapist approaches the be-
havior as a manifestation of an underlying biological              Each therapist in an adjunctive therapy has his or
diathesis and prescribes medication, the approaches             her own boundaries that define the treatment parame-
are not contradictory but do have enormous potential            ters within which the therapist operates. This includes
for confusion and conflict. It is imperative that each           a definition of the therapist–patient relationship and an
therapist involved in adjunctive therapy understand             understanding of what the patient should expect from
not only his or her own theoretical orientation but also        the therapist and what the therapist should expect from
the orientation of all other therapists involved in the         the patient. These expectations include fees, payment
treatment. No therapist can be hidebound by his or her          schedules, cancellation policies, frequency of sessions,
approach and must be respectful and open to other               availability out of session, length of treatment, treat-
points of view.                                                 ment of emergencies, issues of confidentiality, and
   The potential to regard one’s own approach as supe-          many therapy-specific requirements. How each thera-
rior and the other therapies as merely supportive must          pist delineates the boundaries of therapy affects all the
be guarded against, for it inevitably sabotages the treat-      therapists involved in an adjunctive therapy. For exam-
ment. For example, if an individual therapist believes          ple, the individual therapist and the psychopharma-
that medication may relieve symptoms and reduce the             cotherapist must know that their patients will be
patient’s need and motivation for individual therapy, he        thrown out of the substance abuse group they are at-
or she might discourage the patient from taking med-            tending if they test positive twice for drugs or if they
ication or convey to the patient that using medication          fail to produce urine for testing twice. Without this
is a crutch and interferes with the “real” treatment.           knowledge of the group therapist’s boundaries, they
   At times, differences in theoretical perspectives may        could not plan their treatment effectively. With knowl-
lead to different treatment interventions for the identi-       edge of each other’s boundaries, they can plan in ad-
cal clinical situation. While understanding each thera-         vance for this situation and agree that such an event
pist’s treatment boundaries may reduce the potential            would lead to transfer to a rehabilitation facility. An in-
for misunderstanding, appreciating each theoretical             dividual therapist may tell the patient that he or she is
perspective can prevent therapist conflicts. For exam-           unavailable for calls on weekends. The psychopharma-
ple, an individual therapist with a dialectical behavioral      cotherapist needs to know this limit and be prepared to
therapy (DBT) orientation and a physician prescribing           respond if the patient chooses to call him instead.
                                               Adjunctive/Conjoint Therapies                                         19
   One important aspect of therapist boundaries that            have been met. Any of the individual therapies that
overlaps with a following item, communication, is con-          comprise an adjunctive treatment may meet its goals
tent boundaries. It must be clear to all the therapists in-     first. This results in a termination of the therapy and a
volved in an adjunctive therapy and to the patient what         change in other parameters of the treatment. Termina-
information will and will not be shared among all ther-         tion of one component of the therapy, whether it is due
apists. Without this clarity, the patient will be anxious       to a successful outcome or a poor outcome, always ne-
about confidentiality, and the therapists will be uncer-         cessitates a review of the other parameters. This is best
tain about what information they can share. Therapists          carried out if the final parameter, communication, is
need to be clear with each other about what informa-            working well.
tion they need in order to practice comfortably. With-
out this knowledge, a treater may agree with a patient’s
                                                                               F. Communication
request not to share information that other treaters feel
they need to know in order to effectively treat the pa-            The sine qua non for effective adjunctive therapy is
tient. Clearly, effective treatment planning cannot             communication. The therapists must agree on what to
occur without each therapist involved in an adjunctive          communicate, when to communicate, and how to com-
therapy understanding the boundaries of all the thera-          municate. In an adjunctive therapy, the patient has a
pists and without a consideration of potential conflicts         therapist–patient relationship with each of the treaters
related to these boundaries.                                    and must give permission for communication. The
                                                                therapists must agree on what can and cannot be com-
                                                                municated and convey this agreement to the patient.
                       E. Goals                                 Without this clarity, one or more therapists may be
   The goals or expected outcome for adjunctive treat-          working with a handicap. For example, a patient con-
ment need to be explicitly defined for both the patient          veys to an individual therapist that she had several hos-
and the therapists. Inherent in adjunctive therapy is a         pitalizations for psychosis as a young adult. The patient
variation in goals and expected outcome for the differ-         may express concern that the psychopharmacothera-
ent treatments involved. Not only will there be varia-          pist not be told because she is afraid the psychophar-
tion in goals for each therapy but the duration of              macotherapist will hospitalize her. This historical
treatment may vary widely in both length and in pre-            information is crucial to making a correct diagnosis
dictability of length. Group therapies may be rigid in          and in choosing the right medication. Without this in-
length, particularly when the focus is psychoeduca-             formation the psychopharmacotherapist is handi-
tional, or more open-ended, with goals set differently          capped in his or her decision-making process.
for each individual patient. Psychopharmacotherapy              Consequently, in most adjunctive therapies the patient
may have a clear goal of symptom relief but can also in-        is told that no therapist will keep confidential informa-
volve more open-end goals—for example, prophylactic             tion that is deemed crucial for the decision making of
treatment or maintenance treatment with a need for in-          the other therapists. Without such a stipulation, the
definite followup. In addition, the goals of therapies are       lack of communication can provide an avenue for act-
often fluid and change over the course of a treatment.           ing out and resistance.
Illness can evolve over time, requiring a change in                The therapists must also agree on how often to com-
goals. For example, a patient in treatment for alco-            municate and how to communicate. How often is usu-
holism may after a period of abstinence—clearly a suc-          ally driven by the frequency of the therapies, the time
cessful goal of treatment for substance abuse—manifest          of expected change, and the clinical status of the pa-
symptoms of an underlying mood disorder, requiring a            tient. How to communicate depends on the situation
different therapy and a change in treatment goals. Con-         and means available to the therapists. If the adjunctive
sequently, the goals of therapy need to be clearly under-       therapy has all the therapists working in the same set-
stood, and communication among therapists is                    ting sharing a common chart, written communication
necessary to help them avoid conflict in goals, agree            may suffice. More commonly, therapists are working in
when goals are met, and change goals depending on the           disparate settings and unaffiliated programs, so com-
condition of the patient.                                       munication occurs by a regularly scheduled integrated
   Outcomes can affect the other parameters of adjunc-          treatment meeting initiated by the principal therapist.
tive therapy as well. A common occurrence is the suc-           Because such meetings can be resource intensive, they
cessful termination of one therapy because the goals            are often scheduled infrequently. Communication occurs
20                                              Adjunctive/Conjoint Therapies

between meetings by phone conferences, faxing office                 The outcome of this research for psychological treat-
notes, or more recently by e-mail.                               ment has been to reinforce the need of the therapist to
   The areas defining adjunctive therapy, treatment hier-         at least assess all three domains of function and, when
archy, role definition, theoretical clarity, and boundaries       indicated, to plan treatment interventions across all do-
are often fluid, with large areas of overlap. They are            mains. Because of the training, orientation, and experi-
commonly in flux throughout the course of a treatment             ence of a variety of treaters, it has become increasingly
and require active communication as a glue to hold the           common to need the involvement of more than one
treatment together and focused on common goals.                  therapist in treating an individual. This leads directly to
                                                                 the demand for adjunctive therapy.

            II. THEORETICAL BASIS
                                                                           III. HISTORICAL OVERVIEW
   The reasons that individuals seek psychological help
involve many domains—social, psychological, and bio-                The use of adjunctive therapy had its earliest formal
logical, reflecting the complexity of human experience.           use in the United States during the late nineteenth cen-
With the growth of empirical evidence over the last half         tury with the development of moral therapy. Prior to
century, a consensus has built that confining a theory            that time, ill individuals were treated with primarily
of mental illness to a single domain (often the biologic)        physical interventions ranging from herbal treatments,
is reductionistic and ultimately limiting to understand-         bloodletting, isolation, wet packs, rest cures, and, for
ing the illness and likewise its treatment. When mental          severely ill, agitated patients, imprisonment and even
illness occurs, it affects all three domains of human ac-        physical torture. Moral therapy was primarily a social
tivity to varying degrees. Consequently, treatment in-           intervention in which individuals were treated on large
terventions are often made across these domains using            farm-like hospitals and required to participate in the
a variety of therapies.                                          work of the farm. The basic tenet of moral therapy was
                                                                 that if individuals who are profoundly ill are treated
   Starting with DSM-III, American psychiatry made a
                                                                 with respect and dignity and are required to participate
paradigmatic shift defining illness as occurring across
                                                                 in normal social activities rather than be imprisoned
biopsychosocial domains defined by multiaxial diag-
                                                                 and punished, they will once again acquire the social
noses. It is noteworthy that the model for this diagnos-
                                                                 attributes of normal members of society. The large
tic structure was adapted from the New York Heart
                                                                 mental institutions in the United States constructed in
Association criteria for classifying heart disease. Ex-
                                                                 the late nineteenth century were largely working farms.
plicit in this diagnostic approach is an acknowledg-
                                                                 While this earliest example of sociotherapy was often
ment that illnesses span these domains and that                  effective and Charles Dickens described it in glowing
treatment interventions need to be planned across all            terms during his visit to America, it was often not
three domains.                                                   enough. Physical therapies such as isolation, restraints,
   Although research has shown a variety of treatments,          and wet packs were also used frequently to control dis-
including individual treatments (e.g., cognitive behav-          ruptive behavior. Consequently, combinations of both
ioral therapy, interpersonal therapy, and dialectical            physiologic and social therapies were in wide use be-
behavior therapy); group therapies, and psychopharma-            ginning in the last quarter of the nineteenth century.
cotherapy, to be effective treatment for psychiatric ill-           The beginning of the twentieth century saw the
ness, no single treatment addresses dysfunction in all           growth of psychological treatment led by Freud and his
three domains of human experience. This fact is not con-         followers. Psychoanalysis focused on the psychological
fined to psychiatric illness but rather mimics what has           domain of the individual and on how it attributed to
been known about other disorders as well—that illness,           both illness and health. The overriding emphasis was on
regardless of it nature, involves biopsychosocial func-          psychoanalysis as a general theory that both explained
tioning to varying degrees. This has been well-illustrated       and could treat all mental illnesses. Psychoanalysis as a
in oncology by David Spiegel who in 1989 showed that             monotherapy largely dominated treatment for the first
women receiving chemotherapy for breast cancer had               half of the century. Although gravely ill individuals at
better survival rates if they received a time-limited struc-     times received adjunctive therapy, usually, physical treat-
tured group psychotherapy than women treated with                ments such as wet packs, electroconvolsive therapy, and
chemotherapy alone.                                              limited pharmacotherapy, confined largely to sedatives,
                                                Adjunctive/Conjoint Therapies                                          21
these treatments were viewed as more enabling the pa-            and Weisman have demonstrated that certain types of in-
tient to take part in psychoanalyis as an individual treat-      dividual psychotherapy—in this case cognitive-behav-
ment rather than adjunctive therapy per se.                      ioral therapy and interpersonal therapy—are effective
   The growth of adjunctive therapies began after                treatments for this disorder. Pharmacotherapy research
World War II in terms of widespread use, theoretical             has shown that a variety of medications are effective in
interest, and empirical studies. With psychoanalysis as          the treatment of severe and recurrent depression. Strik-
the preeminent treatment, the emphasis was on in-                ingly, both psychotherapy and pharmacotherapy when
trapsychic phenomena and intensive individual treat-             used together to treat depression have better outcomes
ment. The effect of the war was to burden the health             than either used as monotherapy. These types of empiri-
care system, producing more traumatized individuals              cal studies have led to the increasing use of adjunctive
than could possibly be seen in intensive and lengthy             therapy in the current treatment of the mentally ill.
psychotherapy. Group psychotherapy and, in particu-
lar, the empirical and theoretical work of Wilfred Bion
grew directly out of the need to help many psychologi-
cally traumatized individuals with limited resources.
                                                                                   IV. SUMMARY
Frequently, less intensive individual psychotherapy
                                                                    Adjunctive therapy is the use of two or more thera-
was used in conjunction with group psychotherapy,
                                                                 pies to treat the same individual with mental illness.
forcing early theorists to conceptualize how these treat-
ments worked together in complementary ways and,                 This combination may be an individual therapy and
equally importantly, how the therapists collaborated.            group therapy, or couples therapy and individual ther-
   Even as psychoanalysis grew as the preeminent the-            apy. Currently, the most common form of adjunctive
ory and, consequently, the treatment modality, it be-            therapy is the use of individual therapy with psy-
came obvious that psychoanalytic treatment alone                 chopharmacotherapy. The growth of empirical data on a
was often insufficient to treat ill individuals, particu-        variety of adjunctive therapies over the last quarter of a
larly those requiring hospitalization. As the emphasis           century and the acceptance of a biopsychosocial model
of hospitals shifted from social treatment and biologi-          of mental illness as the leading theoretical paradigm
cal therapy to psychoanalytic treatment of the individ-          have made adjunctive therapy increasingly the common
ual, the use of adjunctive therapies and the theoretical         form of modern treatment of mental illness. Depending
understanding of the relationship of these many dif-             on the illness, a variety of adjunctive therapies are cur-
ferent treatments grew. Talcott Parsons, Marshall                rently in use. These adjunctive therapies may be indi-
Edelson, Otto Kernberg, and others addressed the is-             vidual treatment and group treatment, family treatment
sues of sociotherapy—that is, the use of the milieu to           and individual treatment, and psychopharmacotherapy
effect change and complement individual treatment,               and a variety of other therapies. While the combinations
the roles of various therapists in treatment, the effec-         of treatment involved in adjunctive therapy are too nu-
tive domains of varying treatments and how they                  merous to exhaustively catalog identical elements give
complement and compete with each other, the need                 it structure. These elements are treatment hierarchy,
for a mechanism of communication between treaters,               role definition, theoretical clarity, boundary definition
and a hierarchy of treaters.                                     goals, and communication.
   The last quarter of the twentieth century produced
an emphasis on expanding the empirical database, elu-
cidating what therapies work and for what conditions.                    See Also the Following Articles
Led by the work of Aaron Beck, Mardi Horowitz,                   Anxiety Disorders I Cognitive Behavior Group Therapy I
Myrna Weisman, Marsha Linnehan, and others, we                   Individual Psychotherapy I Integrative Approaches to
have vastly increased our knowledge of what kind of              Psychotherapy I Matching Patients to Alcoholism
psychotherapy works and under what conditions. Sim-              Treatment I Psychopharmacology: Combined Treatment I
ilarly, pharmacotherapy research has provided data               Substance Dependence: Psychotherapy
about what medication is effective for what condition.
   This increase in empirical information has highlighted
the fact that no single treatment addresses the ill individ-                      Further Reading
ual’s entire treatment needs. A leading example has been         Applebaum, P. S. (1991). General guidelines for psychia-
the treatment of Major Depressive Disorder. Both Beck              trists who prescribe medications for patients treated by
22                                                 Adjunctive/Conjoint Therapies

  non-medical psychoptherapists. Hospital and Community             Riba, M. B., & Balon, R. (Ed.). (1999). Psychopharmacology
  Psychiatry, 42, 281–282.                                             and psychotherapy: A collaborative approach. Washington,
Ormont, L. R., & Strean, H. S. (1978). The practice of conjoint        DC: American Psychiatric Press.
  therapy: Combining individual and group treatment. New            Stricker, G., & Gold, J. R. (Eds.). (1992). Comprehensive hand-
  York: Human Sciences Press.                                          book of psychotherapy integration. New York: Plenum Press.
                                Adlerian Psychotherapy
                                        Henry T. Stein and Martha E. Edwards
                                Alfred Adler Institute of San Francisco and Ackerman Institute for the Family




    I.   Description of Treatment                                            cial interest, social feeling, and social sense. The concept
   II.   Theoretical Bases                                                   denotes a recognition and acceptance of the interconnect-
  III.   Applications and Exclusions                                         edness of all people, experienced on affective, cognitive,
  IV.    Empirical Studies                                                   and behavioral levels. At the affective level, it is experi-
   V.    Case Illustration                                                   enced as a deep feeling of belonging to the human race
  VI.    Summary                                                             and empathy with fellow men and women. At the cogni-
         Further Reading                                                     tive level, it is experienced as a recognition of interde-
                                                                             pendence with others, that is, that the welfare of any one
                                                                             individual ultimately depends on the welfare of everyone.
                            GLOSSARY                                         At the behavioral level, these thoughts and feelings can
                                                                             then be translated into actions aimed at self-development
antithetical scheme of apperception The sharply divided way                  as well as cooperative and helpful movements directed to-
   of interpreting people and situations with an “either/or,”                ward others. Thus, at its heart, the concept of feeling of
   “black and white” restriction of qualities; no “grey area” is             community encompasses individuals’ full development of
   acknowledged.                                                             their capacities, a process that is both personally fulfilling
compensation A tendency to make up for underdevelopment                      and results in people who have something worthwhile to
   of physical or mental functioning through interest and train-             contribute to one another.
   ing, usually within a relatively normal range of develop-              feeling or sense of inferiority (primary and secondary) The
   ment. Overcompensation reflects a more powerful impulse                    primary feeling of inferiority is the original and normal
   to gain an extra margin of development, frequently beyond                 feeling in the infant and child of smallness, weakness, and
   the normal range. This may take a useful direction toward                 dependency. This usually acts as an incentive for develop-
   exceptional achievement or a useless direction toward ex-                 ment. However, a child may develop an exaggerated feel-
   cessive perfectionism. Genius may result from extraordinary               ing of inferiority as a result of physiological difficulties
   overcompensation. Undercompensation reflects a less ac-                    (e.g., difficult temperament) or handicaps, inappropriate
   tive, even passive attitude toward development that usually               parenting (including abuse, neglect, pampering), or cul-
   places excessive expectations and demands on other people.                tural or economic obstacles. The secondary inferiority feel-
eidetic imagery Vivid, detailed visualizations of significant fig-             ing is the adult’s feeling of insufficiency that results from
   ures in a person’s life used to yield projective impressions              having adopted an unrealistically high or impossible com-
   and stimulate emotional responses during the diagnostic                   pensatory goal, often one of perfection. The degree of dis-
   phase of therapy. Later in therapy, these visualizations can              tress is proportional to the subjective, felt distance from
   be modified to promote therapeutic changes.                                that goal. In addition to this distress, the residue of the
feeling of community (social interest) Translated from the                   original, primary feeling of inferiority may still haunt an
   German, Gemeinschaftsgefühl, as community feeling, so-                    adult. An inferiority complex is an extremely deep feeling



Encyclopedia of Psychotherapy                                                                           Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                             23                                                     All rights reserved.
24                                                       Adlerian Psychotherapy

   of inferiority that can lead to pessimistic resignation and           chological direction, without internal contradictions or
   an assumed inability to overcome difficulties.                         conflicts.
fictional final goal An imagined, compensatory, self-ideal cre-
   ated to inspire permanent and total relief, in the future,
   from the primary inferiority feeling. Often referred to as               I. DESCRIPTION OF TREATMENT
   simply the person’s goal, it is usually unconscious until
   uncovered in psychotherapy.
missing developmental experience A belated therapeutic sub-
                                                                          The primary indication of mental health in Adlerian
   stitute for toxic, deficient, or mistaken early family, peer, or     psychotherapy is the person’s feeling of community and
   school experiences.                                                 connectedness with all of life. This sense of embedded-
organ jargon An organ’s eloquent expression of an individual’s         ness provides the real key to the individual’s genuine
   feelings, emotions, or attitude. Usually an ultrasensitive          feeling of security and happiness. When adequately de-
   organ sends a symbolic message of the individual’s distress         veloped, it leads to a feeling of equality, an attitude of
   about a subjectively unfavorable psychological situation.           cooperative interdependency, and a desire to con-
private logic versus common sense Private logic is the reason-         tribute. Thus, the central goal of psychotherapy is to
   ing invented by an individual to stimulate and justify a            strengthen this feeling of community.
   self-serving style of life. By contrast, common sense repre-
                                                                          The major hindrance to a feeling of equality and the
   sents society’s cumulative, consensual reasoning that rec-
                                                                       development of the feeling of community is an exag-
   ognizes the wisdom of mutual benefit.
psychological movement The thinking, feeling, and behavioral           gerated inferiority feeling for which the individual at-
   motions a person makes in response to a situation or task.          tempts to compensate by a fictional final goal of
safeguarding tendencies Strategies used to avoid or excuse             superiority over others. Thus, the therapeutic process
   oneself from imagined failure. They can take the form of            is simultaneously focused on three aspects of change.
   symptoms—such as anxiety, phobias, or depression—                   One is the reduction of the painful, exaggerated inferi-
   which can all be used as excuses for avoiding the tasks of          ority feelings to a normal size that can be used to spur
   life and transferring responsibility to others. They can also       growth and development and a healthy striving for sig-
   take the form of aggression or withdrawal. Aggressive               nificance. A second is the dissolution of the patient’s
   safeguarding strategies include depreciation, accusations,          corrosive striving for superiority over others, emboided
   or self-accusations and guilt, which are used as a means of
                                                                       in a compensatory style of life. A third is the fostering
   elevating a fragile self-esteem and safeguarding an
   overblown, idealized image of oneself. Withdrawal takes
                                                                       of equality and feeling of community. Underlying this
   various forms of physical, mental, and emotional distanc-           work is a firm belief in the creative power of the indi-
   ing from seemingly threatening people and problems.                 vidual, to freely make choices and correct them, thus
Socratic-therapeutic method An adaptation of the Socratic              providing an encouraging perspective on responsibility
   style of questioning specifically tailored to eliciting and          and change.
   clarifying information, unfolding insight, and promoting               Adlerian psychotherapy is a creative process in
   change in Classical Adlerian psychotherapy.                         which the therapist invents a new therapy for each
striving for significance The basic, common movement of                 client. Six phases of the therapeutic process are as fol-
   every human being—from birth until death—of overcom-                lows: (1) establishing the therapeutic relationship, (2)
   ing, expansion, growth, completion, and security. This
                                                                       assessment, (3) encouragement and clarification, (4)
   may take a negative turn into a striving for superiority or
                                                                       interpretation, (5) redirection of the lifestyle, and (6)
   power over other people. Unfortunately, many reference
   works mistakenly refer only to the negative “striving for           meta-therapy. These are briefly offered with the caveat
   power” as Adler’s basic premise.                                    that for any particular client, the actual therapeutic
style of life A concept reflecting the organization of the per-         process may look quite different.
   sonality, including the meaning individuals give to the
   world and to themselves, their fictional final goal, and the
   affective, cognitive, and behavioral strategies they employ                    A. Phase I: Establishing the
   to reach the goal. This style is also viewed in the context of                  Therapeutic Relationship
   the individual’s approach to or avoidance of the three tasks
   of life: other people, work, love, and sex.
                                                                         Developing a cooperative working relationship is
tendentious appreception The subjective bending of experi-             fundamental for any meaningful therapeutic progress.
   ence in the direction of the fictional final goal.                    A warm, caring, empathic bond, established from the
unity of the personality The position that all of the cognitive,       very beginning, opens the door for gradual, positive in-
   affective, and behavioral facets of the individual are viewed       fluence. Initially, the client may need to express a great
   as components of an integrated whole, moving in one psy-            deal of distress with little interruption. In response,
                                                   Adlerian Psychotherapy                                                25
therapist offers genuine warmth, empathy, understand-            and day dreams, and (7) information about the larger
ing, and empathy. An atmosphere of hope, reassurance,            contexts in which the patient is embedded (e.g., ethnic,
and encouragement enables the client to develop a feel-          religious, class, gender, or racial contexts). Although
ing that things can be different.                                much of this information can be collected in the early
   The therapist also helps the client learn to participate      therapy sessions, it can also be obtained in writing both
in a cooperative relationship. The success of the ther-          to save time and to draw on information from a different
apy depends on how well the patient and therapist                mode. When appropriate, intelligence, career, and psy-
work together, each doing his or her part, which in-             chological testing are included.
cludes the client’s thinking and action between visits.             The therapist uses both cognitive and intuitive
   The relationship with the therapist is a major avenue         processes to integrate this diagnostic information into a
for significant change. The therapist provides belated            unique, vivid, and consistent portrait. This is key to
parental influence to provide what was missing in the             treatment planning and will eventually and gradually
patient’s early childhood or to ameliorate toxic early           be shared with the client. The therapist must always
experiences. The therapist helps the patient experience          keep in mind, however, that these conclusions are
a relationship based on respect, equality, and honesty—          somewhat tentative and are subject to refinement and
for some patients the first such relationship they have           revision. As the therapist gains more information, it
ever experienced. The therapist also provides a good             must all fit in with this portrait in a consistent way; if
model of cooperation and caring.                                 not, the portrait may need revisions to accommodate
                                                                 this new information.
            B. Phase II: Assessment
                                                                            C. Phase III: Encouragement
   A through assessment is a critical step in Adlerian
psychotherapy, for it will guide much of the therapeu-
                                                                                 and Clarification
tic process. Although it is generally conducted during              An ongoing central thread throughout the entire
the first part of the treatment, information obtained             therapeutic process is encouragement. The therapist
throughout treatment may be used to refine and even               cannot give clients courage; this feeling must develop
correct initial impressions and interpretations. The ob-         through the gradual conquest of felt difficulties. The
jective of the assessment process is to conduct a com-           therapist can begin this process by acknowledging the
prehensive analysis of the patient’s personality dynamics        courage the client has already shown, for example, in
and the relationship among the—what Adler called the             coming to therapy. Then the therapist and client to-
style of life. At a minimum, this analysis includes an           gether can explore small steps that, with a little more
identification of the patient’s inferiority feelings, fic-         courage, the client might take. For many clients, this is
tional goal, psychological movement, feeling of com-             equivalent to doing the “felt impossible.” During and
munity, level and radius of activity, scheme of                  after these steps, new feelings about efforts and results
apperception, and attitude toward the three life tasks           are acknowledged and discussed.
of occupation, love and sex, and other people.                      In attempting to avoid failure, discouraged people
   A central assessment technique that Adler pioneered           often decrease their level and radius of activity. They
is the projective use of early memories. These memo-             can become quite passive, wait for others to act, and
ries—whether they are “true” or fictional—embody a                limit their radius of activity to what is safe or emotion-
person’s core beliefs and feelings about self and the            ally profitable. If this is true for a patient, the therapist
world and reflect the core personality dynamics. In ad-           and patient need to find ways to increase the patient’s
dition to these early memories, the therapist uses the           activity level—to increase initiative and persistence,
following: (1) a description of symptoms and difficul-            completion of tasks, improvement of capacities, and
ties, the circumstances under which they began, and the          enjoyment of progressively vigorous effort. If the activ-
client’s description of what he would do if not plagued          ity radius is too narrow, a broadening of interests may
with these symptoms; (2) current and past functioning            provide stimulation, challenge, and more pleasure. In
in the domains of love relationships, family, friendships,       increasing activity level, however, a client may initially
school, and work; (3) family of origin constellation and         move in a problematic direction; for example, a timid
dynamics, and extended family patterns, (4) health               person aggressively tells off his friend. But this is often
problems, medication, alcohol, and drug use, (5) previ-          a necessary first step that can be corrected after com-
ous therapy and attitude toward the therapist; (6) night         mending the attempt.
26                                                      Adlerian Psychotherapy

  During this still-early phase of therapy, Socratic                  cial result is the best clue to discovering a goal. Trans-
questioning is used to clarify the client’s core beliefs              lating actions, thoughts, and feelings into movement
and feelings about self, others, and life. Here is a brief            and interpreting them in clear, simple, nontechnical
example of Socratic questioning in a therapy session                  language provides a useful mirror for the client. Buzz-
with a depressed man who is stuck in his symptoms.                    words, jargon, and typologies do not help as much, fre-
                                                                      quently obscuring the uniqueness of the client’s
       T: You may have a suggestion, you’re kind of bright,           experience. The therapist uses everyday terminology
   you know.                                                          and even tries to form insight in terms of images that
       C: What makes you think I’m bright?                            are familiar to the client.
       T: By the way you talk, and the way you answer                    In the therapeutic dialogue, the therapist will also di-
   questions, and the way you do things in general. You’re
                                                                      alectically question the client’s antithetical scheme of ap-
   bright. You know how to avoid giving an answer, and
   how to aggravate people, and you know a lot of things.
                                                                      perception. The client is likely to resist this process
   That’s kind of bright. Dumb people don’t do that.                  because the scheme of apperception provides certainty
       C: You think that’s a sign of brightness, to aggravate         and supports the pursuit of the childlike, egocentric,
   people?                                                            final goal. The client’s scheme of apperception depends
       T: Oh, sure! That’s a way that you use it. I don’t par-        on cognitive rigidity to generate very strong feelings. It
   ticularly think that people approve of the way you use             locks the client into a dichotomized, superior/inferior
   it, but it is a sign of brightness. You could use the same         way of seeing the world, evaluating experiences, and
   brightness in a different way, you know?                           relating to others. Thus, to loosen and dissolve the an-
       C: That’s true. A lot of people are very annoyed at            tithetical scheme of apperception, the therapist must
   me.                                                                help the client see the real and subtly distinguishing
       T: Uh huh. You like that?                                      qualities of people and experiences rather than divid-
       C: Sometimes I don’t mind. It bothers me when my
                                                                      ing impressions into “either or,” rigidly absolute cate-
   parents get annoyed at me because then I can’t go visit
                                                                      gories.
   them. And they won’t let me visit every week.
       T: They won’t let you visit every week. Now if I                  All behavior is purposive and is aimed at moving to-
   would be very annoying, would you like me to visit                 ward the final goal. Client’s emotions and symptoms
   you every week?                                                    will all serve the goal. The purpose may be hidden, and
       C: (weakly) I don’t think so.                                  the client may not want to acknowledge responsibility
       C: No. Sounds as if your parents have a point.                 for his intention. Both emotions and symptoms can be
                                                                      used to avoid responsibility for actions or as excuses
   The therapist builds on a strength of the client—his               for not doing what the client really does not want to do.
intelligence. Then she brings out the client’s private                For example, fear, confusion, and anger can all be used
logic, which could be expressed as, “I can annoy oth-                 as excuses for not developing better relationships with
ers with impunity.” She then tests this private logic by              others. The client needs to understand how he uses or
extending it to others, asking whether this logic could               abuses emotion. Does he create feelings that help him
also be applied to the therapist annoying the client.                 do the right thing? Does he use strong emotion as an
Using Socratic questioning to challenge the client’s                  excuse for indulgent and irresponsible action? What
private logic helps him to move closer to common                      emotions does he avoid? Does one client, for example,
sense.                                                                aggressively ward off tender emotions, while another
   As the client and therapist talk during these early                avoids anger with his “nice guy” approach? What is the
sessions, the therapist focuses on the psychological                  impact of the client’s emotions on other people? Does
movement within the client’s expressions and imagines                 he want this result? Emotions are not the cause of be-
the goal toward which the movements lead. For exam-                   havior: rather, they serve one’s intentions.
ple, while the client may talk about a conflict with his                  One of Adler’s favorite diagnostic questions was, “If
wife, two possible movements he could actually be de-                 you did not have these symptoms, what would you
scribing are away from his wife (withdrawal) or against               do?” The answer frequently revealed what responsibil-
his wife (aggression). By doing this, the therapist be-               ity or challenge the person was trying to avoid. Symp-
gins to identify the client’s immediate and long-range                toms, like crutches, will be discarded when they are no
hidden goals. He may be trying to protect himself from                longer needed. Trying to treat the symptom is like
psychological harm, or he may wish to punish her for                  blowing away smoke without extinguishing the fire
real or imagined hurts. Frequently, the immediate so-                 that causes it.
                                                   Adlerian Psychotherapy                                               27

          D. Phase IV: Interpretation                            inferiority feeling behind him so that it pushes him
                                                                 ahead. That’s the purpose of the normally sized inferi-
   After the client has made some movements toward               ority feelings—to motivate development. If, however,
change and she and the therapist have examined the               the client’s feeling of inferiority is quite exaggerated
meaning of her movements and immediate goals, they               and seems to immobilize him or thrust him into wildly
eventually engage in an interpretation of the client’s           ambitious plans that are destined for failure, the thera-
style of life. Discussing and recognizing these core per-        pist helps him change his thinking about his assumed
sonality dynamics, such as the inferiority feeling or the        great deficiency.
goal, can be both painful and even embarrassing. The                When the client’s inferiority feelings are exaggerated,
interpretation process requires diplomacy, exquisite             the superiority striving gets corrupted into striving for
timing, and sensitivity. Doing this interpretation too           superiority over others rather than for development
soon is discouraging. The style of life is interpreted           and growth. Thus, another therapeutic process in-
gradually, as the client gains success and strength in a         volves redirecting this striving into a more positive di-
new direction, discovers capacities that she has neg-            rection—the conquest of real personal and social
lected, and begins to correct what she has omitted in            difficulties that benefit others rather than the superior-
her development. Once she has moved sufficiently in a             ity and power over other people.
new direction, the results of her new and old attitudes             A thread that runs through the therapy and that un-
are then compared.                                               derlies efforts to reduce inferiority feelings is the way
   This insight enables the client to take greater initia-       the therapist promotes the feeling of equality. The ther-
tive in interpreting situations more on her own, sharing         apist’s offer of equality may be a new experience that
her own ideas with the therapist. Many clients are               the client can gradually transfer to other people.
tempted to terminate at this point, feeling that they               As the client begins to feel more able and less infe-
know enough, even though they have not actually ap-              rior, she may be able to begin changing her fictional
plied their insight and changed their main direction in          final goal. The compensatory, fictional final goal, origi-
life. However, profound change occurs after the client           nally formed to relieve the primary feeling of inferior-
and therapist have together identified and discussed              ity, can gradually be modified to a more cooperative
the client’s style of life. Insight and newly found              form, or dissolved and replaced by a different form of
courage are mobilized to approach old difficulties and            motivation. Abraham Maslow described this higher
neglected responsibilities. On the basis of this insight,        level of functioning as “growth motivation,” in contrast
then, the client can work toward lifestyle redirection,          to the lower level of “deficiency motivation.” A client
that is, changing the main direction of movement and             makes the choice to abandon his former direction and
approaching the three central tasks of life (community,          pursue the new one because it yields a more positive
work, and love).                                                 feeling of self and greater appreciation from others. As
                                                                 the goal changes, the rest of the style of life also
                                                                 changes as old feelings, beliefs, and behaviors are no
   E. Phase V: Style of Life Redirection
                                                                 longer required in the new system.
   This phase represents the depth work that is done for            Parallel to the process of reducing inferiority feelings
the client to redirect the lifestyle This requires reducing      and changing the goal is the process of increasing the
and using inferiority feelings, redirecting the superior-        feeling of community. Initially, through his contact
ity striving, changing the fictional final goal, and in-           with the therapist and later through his application of
creasing the feeling of community.                               social interest with other people, the client learns the
   Clients may have exaggerated inferiority feelings             meaning and value of contact, connectedness, belong-
that they want to eliminate totally, believing that if           ing, and empathy. Gemeinschaftsgefühl, the original
they realize their goal, these painful feelings will disap-      German term for community feeling, expresses a very
pear. A client may use his feeling of inferiority to build       profound philosophical perspective on life—a very
a wall in front of him, thereby excusing himself from            deep feeling for the whole of humankind, an attitude of
difficult effort and from risk to his fictional ideal. His         vigorous cooperation and social improvement, and a
depreciation of others, fictional superiority posturings,         sense of the interconnectedness of all of life and nature.
alcohol, or drugs may temporarily give him some relief              Perhaps skeptical of the therapist’s good-will at first,
from his semi-hidden and dreaded feeling of defi-                 the client has felt and appreciated the genuine caring
ciency. The therapeutic aim is to help the client put an         and encouragement. The conquering of obstacles has
28                                                 Adlerian Psychotherapy

generated courage, pride, and a better feeling of self           positive or negative models. How the therapist behaves
that now lead to a greater cooperation and feeling of            is critical, for it may interfere with the therapy process if
community with the therapist. This feeling can, and              a client sees that his therapist does not embody what
should, now be extended to connect more with other               she is trying to teach him. Thus, providing an honest
people, cooperate with them, and contribute signifi-              example of cooperation and caring is fundamental. It is
cantly to their welfare. As the client’s new feeling of          not enough for a therapist to understand and talk about
community develops, she will become motivated to                 Adler’s ideas; they must also be lived. If a client sees any
give her very best to her relationships and to her work.         contradiction between the therapist’s words, feelings,
   Throughout the therapeutic process—both before                and actions, he has good reason to be skeptical.
and after the formal interpretation process—the thera-
pist and client have been working on correcting the
                                                                            F. Phase VI: Meta-Therapy
client’s private logic and dissolving the antithetical
scheme of apperception. In addition to these processes,             A few clients may reach the quest for full personal
it may be helpful to engage in therapeutic strategies            development. The challenge is to stimulate each client
that change the negative imprints from the past.                 to become her best self in the service of others, to
   If the client’s early childhood experience was very           awaken her inner voice, and to fully use her creative
negative or deficient, it may be helpful to help the              powers. Müller described the last phase of therapy as a
client counteract the haunting memories of abuse or              “philosophical discourse.” For those clients who need
neglect with creative, nurturing images. Some people             and desire this experience, Classical Adlerian psy-
respond to a vivid description and discussion of how             chotherapy offers the psychological tools and philo-
they could have been parented. It gives them a picture           sophical depth to realize their quest.
of what might have happened, how it could have felt,                Maslow labeled this latter aspect of therapy “meta-
and the outcomes that could have resulted. It may also           therapy.” He suggested that the fullest development of
serve as a model for what the client could do in his or          human potential might require a more philosophical
her own parenting.                                               process, one that went beyond the relief of suffering
   Other clients prefer the use of guided imagery to             and the correction of mistaken ideas and ways of living.
change the negative imprints of significant others that           As clients improve, the therapist can help them see that
weigh heavily on them and often ignite chronic feelings          they can use new, more liberating and inspiring guides
of guilt, fear, and resentment. Still others prefer role-        for their lives. These alternative guides are what
playing both to add missing experiences to their reper-          Maslow called meta-motivation or higher values—for
toire and to explore and practice new behavior in the            example, truth, beauty, justice. The values that individ-
safety of the therapist’s office.                                 ual clients choose will depend on their unique sensitiv-
   To provide missing experiences—for example, sup-              ities and interests.
port and encouragement of a parent—a group setting is
recommended. Group members, rather than the thera-
pist, can play the roles of substitute parents or siblings.                  II. THEORETICAL BASES
In this way, a client can engage in healing experiences,
and those who participate with him can increase their               Classical Adlerian psychotherapy is both similar to
own feeling of community by contributing to the                  and distinctively unique to some contemporary schools
growth of their peers.                                           of psychology and psychotherapy. In its focus on the
   The client and therapist can engage in role-playing           importance of the relationship between the client and
for learning and practicing new behaviors. The thera-            early childhood significant others, between the client
pist can model possible behaviors as well as coaching,           and therapist, and between the client and significant
encouraging, and giving realistic feedback about proba-          others in his life, it is similar to self psychology and ob-
ble social consequences of what the client plans to do.          ject relations psychotherapies. In its recognition of the
This is somewhat equivalent to the function of chil-             embeddedness of the individual within a social con-
dren’s play as they experiment with roles and situations         text, it is similar to social psychology and family sys-
in preparation for growing up.                                   tems therapy. In its focus on the subjective meaning the
   A final issue of therapeutic change in the Classical           client makes of the world and his relationship to it, it is
Adlerian model is the person of the therapist. Clients           similar to constructivist theories and cognitive-behav-
constantly observe their therapists and may use them as          ioral psychotherapy.
                                                   Adlerian Psychotherapy                                               29
   But several conceptual aspects of Classical Adlerian          ence, from an Adlerian perspective, is the tendency of
psychotherapy set it apart from all others. First and fore-      the client to transfer inappropriate positive or negative
most is the conception of the creative power of the indi-        feelings, originally experienced toward a parent, sib-
vidual that is directed toward a goal, a fictional future         ling, or other significant figure from childhood, toward
reference point that pulls all movements in the same di-         the therapist. Adler considered the client’s transference
rection. An Adlerian psychotherapist never asks the              a device to justify and protect the pursuit of the hidden,
question, “What makes the client do that?” The question          fictional final goal. Consequently, the therapist diplo-
is always, “What is the client trying to achieve by doing        matically unveils the transfer of perception and feeling
that?” Underlying this teleological approach is a belief in      as a long-standing habit that needs to be corrected. In
active, free will to creatively move toward a goal of one’s      this perspective, transference is a resistance to the co-
own choosing. But once having adopted a fictional final            operation that is necessary between client and thera-
goal, the goal functions unconsciously, out of full aware-       pist. The client usually tries to draw the therapist into a
ness. (This concept of fictional final goal is similar to          familiar relationship where she can imagine an even-
that of a strange attractor in chaos theory, a magnetic end      tual secret victory.
point that pulls on and sets limits for a process.)                 Countertransference, the therapist’s reactions to the
   This goal also organizes the psychological move-              client, are used by the Adlerian therapist as clues to the
ments of the person so that there is a unity of the per-         effect that the client has on others in her life. If, how-
sonality. One part of the personality never wars with            ever, the therapist finds that the client triggers his own
another; all cooperate together in the service of the            unfinished personal issues, this should prompt the
goal. What may look like conflict—for example, a                  therapist to deal with these in his study analysis with a
client is ambivalent about whether to remain monoga-             senior training analyst.
mous in his marriage or to have an affair—is really in
service of a final goal—to avoid giving himself com-
pletely to one woman. Emotions are also the servants of                          III. APPLICATIONS
this goal—for example, fear used to avoid, anger used                            AND EXCLUSIONS
to dominate, punish, or create distance. Dreams reflect
this goal, as do daydreams, early recollections, and                The strategies of Classical Adlerian psychotherapy
everyday behaviors. (This concept of unity, in which             are similar in individual, couple, family, and child psy-
one central theme is reflected in every psychological             chotherapy. The central dynamic is the encouragement
expression, is similar to the concept in physics of the          of each individual to develop his or her capacities so as
hologram, wherein each part of a whole is an enfolded            to reduce the inferiority feeling, to feel more equal with
image of that whole.)                                            others, to become more cooperative, and to contribute
   Another central aspect of Classical Adlerian psy-             to the improvement of all relationships for mutual ben-
chotherapy is the values on which it is based. Adler used        efit. In order to accomplish this, the style of life of each
to say that if humans didn’t learn to cooperate, they            person usually needs to be redirected. Abbreviated
would annihilate the world. Thus, therapy encompasses            adaptations of Classical Adlerian psychology have also
much more than simple relief from symptoms. The goal             been developed for use in brief therapy, career assess-
of therapy is to increase the client’s feeling of community      ment and guidance, organizational consulting, and
so that she can better cooperate with others and make a          child guidance for parents and teachers.
contribution to the whole of life. Over the course of his
theoretical development, Adler moved from viewing hu-
mans as simply attempting to compensate for inferiority                      IV. EMPIRICAL STUDIES
feelings (what Maslow called “deficiency motivation”) to
a focus on growth and development (what Maslow                     As of yet, there have been no empirical studies of
called “growth motivation”). Thus, in Classical Adlerian         Classical Adlerian psychotherapy.
psychotherapy, the aim is to move towards optimal psy-
chological, philosophical, and even spiritual health for
the benefit of both self and others.                                          V. CASE ILLUSTRATION
   Unlike traditional psychoanalysis, Classical Adlerian
psychotherapy does not utilize transference or counter-             Arthur, a lonely, angry man in his mid-40s, was re-
transference as cornerstones of treatment. Transfer-             ferred to therapy after completing an outpatient alco-
30                                                Adlerian Psychotherapy

hol treatment program. He was very frustrated with his          as a child and as an adult—warm, friendly contact with
career as a criminal investigator, experienced very little      other people. He appreciated the therapist’s under-
intimacy with his wife, and had no friends. Although            standing of his early family situation and empathy for
he conducted extremely thorough investigations that             his lonely childhood suffering. Socratically, he became
resulted in convictions, sentences rarely included jail         aware of his narrow focus of interest on the people who
time. His cold and isolated childhood left him very bit-        made trouble and his exclusion of those who offered af-
ter: his memories were of an unhappy mother; a remote           fection and caring.
father; and a hell-raising older brother whom he hated,            Eventually, he softened enough to respond to heal-
but who was the center of the parents’ attention and            ing, eidetic images of warmer, caring “substitute” par-
frequently got away with illegal behavior. By contrast,         ents. These images elicited his first experience of crying
he was a compliant youngest child who didn’t make               in therapy. After opening up emotionally and experi-
any trouble and was ignored. His sister, the oldest sib-        encing a gradual series of missing developmental expe-
ling, acted as a substitute caretaker for the distracted        riences through guided and eidetic imagery, he
and critical mother.                                            overcame a socially corrosive depreciation tendency to-
   The felt neglect of his father and the lack of love          ward wrongdoers, and was willing to redirect his striv-
from his mother were at the roots of his inferiority feel-      ing for significance into an interest in promoting
ings—a painful sense of being unloved and ignored.              understanding and fairness, instead of administering
Discouraged and pessimistic about gaining affection             punitive justice. He concluded treatment with a more
and attention, he directed his compensatory lifestyle           comfortable, closer relationship with his wife, and an
toward catching as many “bad guys” as he could and              optimistic perspective on making new friends.
seeing that they were locked up. Since most were not,
in his estimation, adequately punished, he was perpet-
ually frustrated. He also viewed his parents and brother                          VI. SUMMARY
as unpunished criminals. His unconscious goal was to
secure compensation and revenge for his miserable                  In its most basic of descriptions, Adler conceived of
childhood. Revenge was not working out to his satis-            the goal of therapy to help clients connect themselves
faction, but at least he could look forward to a comfort-       with fellow men and women on an equal and cooper-
able retirement, a symbol of what he felt entitled to.          ative footing. Therapist and client simultaneously
   Initially, his attitude toward the therapist was             focus on three therapeutic processis: (1) reducing
guarded and minimally expressive. What made him                 painful, exaggerated inferiority feelings to a normal
competent in surveillance work, observing others with-          size that can be used to spur growth and development
out being seen, was a handicap in making a personal             and a healthy striving for significance; (2) redirecting
relationship. However, two strengths could be built on.         the lifestyle away from a useless and corrosive striving
First, he had conquered both alcohol and nicotine de-           for superiority over others and fictional final goal and
pendencies. Second, his intense curiosity about hidden          toward a more useful and cooperative direction; and
information and details provided a stimulus for exam-           (3) fostering equality and a feeling of community.
ining his own style of life thoroughly through a discus-        Thus, not only does therapy benefit the individual,
sion of the vivid clues embedded in his earliest                but it also contributes to the improvement of life for
childhood recollections. His most revealing recollec-           other people.
tion featured his brother spoiling a family fishing trip
by making trouble and then getting away with it. His
antithetical scheme of apperception sharply divided the                See Also the Following Articles
good guys who obeyed the laws and the bad guys who              Countertransference I Dreams I History of Psychotherapy
broke the laws.                                                 I Interpersonal Psychotherapy I Jungian Psychotherapy I
   His private logic dictated that those who followed           Objective Assessment I Sullivan’s Interpersonal
the rules were entitled to generous rewards and that the        Psychotherapy I Transference
criminals deserved harsh punishment and confine-
ment. Through his work, he dreamed of the ultimate
                                                                                 Further Reading
compensation denied his as a child: punishing lots of
bad people. Gradually, he realized how much his cru-            Ansbacher, H. L., & Ansbacher, R. (Eds.). (1956). The indi-
sade had driven his life and what he had been missing,            vidual psychology of Alfred Adler. New York: Basic Books.
                                                      Adlerian Psychotherapy                                                     31
Davidson, A. K. (Ed.). (1991). The collected works of Lydia         Stein, H. (1988). Twelve stages of creative Adlerian psy-
   Sicher: An Adlerian perspective. Fort Bragg, CA: QED                chotherapy. Individual Psychology, 44, 138–143.
   Press.                                                           Stein, H. (1990). Classical Adlerian psychotherapy: A Socratic
Ellenberger, H. (1970). The discovery of the unconscious: The          approach. Audiotape study program. Alfred Adler Institute
   history and evolution of dynamic psychiatry. New York: Basic        of San Francisco, San Francisco.
   Books.                                                           Stein, H. (1991). Adler and Socrates: Similarities and differ-
Hoffman, E. (1994). The drive for self. New York: Addision-            ences. Individual Psychology, 47, 241–246.
   Wesley.                                                          Stein, H., & Edwards, M. (1998). Classical Adlerian theory
Maslow, A. (1971). The farther reaches of human nature. New                              .
                                                                       and practice. In P Marcus & A. Rosenberg (Eds.), Psycho-
   York: Penguin Books.                                                analytic versions of the human condition: Philosophies of life
Müller, A. (1992). You shall be a blessing. Alfred Adler Insti-        and their impact on practice. New York: New York Univer-
   tute of San Francisco, San Francisco.                               sity Press.
                      Alternatives to Psychotherapy
                                                  Janet L. Cummings
                                         The Nicholas & Dorothy Cummings Foundation




    I. Technical Alternatives to Psychotherapy                        digoxin A prescription cardiac medication that strengthens
   II. Pharmacologic (Herbal) Alternatives to Psychotherapy              and regulates the heartbeat, available as pills, IM injection,
  III. Summary                                                           or IV injection.
       Further Reading                                                dopamine A neurotransmitter involved in motor control, in-
                                                                         creased levels of which are associated with psychosis.
                                                                      EMDR (See eye movement desensitization and reprocessing).
                            GLOSSARY                                  ephedra Also known as ma huang; an herbal compound with
                                                                         amphetamine-like qualities sold over-the-counter in a
5-hydroxytryptophan (See five-hydroxytryptophan).                         number of weight-loss and energy-boosting products.
agonist A drug that works by stimulating its receptor (as op-         eye movement desensitization and reprocessing (EMDR) An
   posed to an antagonist, which works by blocking receptors).           alternative to psychotherapy that utilizes eye movements
anesthetics Drugs used for general anesthesia.                           or other left-right stimulation to treat psychological
Aristolochia fangchi Also called guang fang ji, an herb mar-             problems.
   keted over-the-counter for weight loss in products labeled         five-hydroxytryptophan (5-hydroxytryptophan) Also called
   “Chinese herbs.”                                                             ,
                                                                         5-HTP an herbal supplement marketed for the treatment
aristolochic acid A chemical found in the Chinese herb Aris-             of depression, which is metabolized into serotonin in the
   tolochia fangchi, which is sold over-the-counter in various           body and may enhance serotonin neurotransmission.
   weight-loss products.                                              fluoxetine (Prozac) A selective serotonin reuptake inhibitor.
autonomic nervous system The branch of the nervous system             formulary A list of drugs that are included as covered bene-
   that regulates internal body processes requiring no con-              fits by a particular insurance company, as opposed to non-
   scious awareness.                                                     formulary drugs that must be purchased out-of-pocket or
barbiturates A class of drugs (including pentobarbital and               with a higher co-payment.
   phenobarbital) used to induce sleep, relieve anxiety, treat        GABA (See gamma-aminobutyric acid).
   certain types of seizures, or for general anesthesia.              gamma-aminobutyric acid The major inhibitory neurotrans-
benzodiazepines A class of drugs (including Valium, Lib-                 mitter of the central nervous system.
   rium, and Xanax) that decrease anxiety and induce sleep            Griffonia simplicofolia An African plant, the seeds of which
   by facilitating GABA neurotransmission.                               are used to derive 5-hydroxytryptophan.
carbidopa A prescription drug used to treat Parkinson’s dis-          guang fang ji (See Aristolochia fangchi).
   ease, available in pill form.                                      heliotrophe (See Valerianae radix).
carcinogenicity Cancer-promoting properties.                          hematocrit A measure of the proportion of red blood cells to
cyclosporine Prescription immunosuppressant medication                   the total blood volume.
   used to prevent organ rejection in transplant recipients,          hemoglobin The oxygen-carrying component of red blood
   available in pills, oral solution, or IV injection.                   cells.



Encyclopedia of Psychotherapy                                                                        Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                         33                                                      All rights reserved.
34                                                  Alternatives to Psychotherapy

homocysteine A substance in the blood, high levels of which          scleroderma A chronic disease characterized by blood vessel
   are associated with increased risk of heart disease.                 abnormalities, as well as degenerative changes and scar-
Hypericum perforatum Also called St. John’s wort; an herbal             ring of the skin, joints, and internal organs.
   compound marketed over-the-counter for the treatment of           selective serotonin reuptake inhibitors (SSRIs) A class of anti-
   depression, which likely affects the serotonin system.               depressants (including Prozac, Zoloft, and Paxil) that
immunosuppressant A drug used to prevent transplant rejec-              work by blocking the reuptake of the neurotransmitter
   tion or to treat autoimmune disorders or severe allergies,           serotonin.
   which suppresses the functioning of the immune system.            serotonin A neurotransmitter, decreased levels of which are
inhibitory neurotransmitter A neurotransmitter, the presence            associated with depression.
   of which decreases the probability of neuronal firing (as          serotonin syndrome A syndrome caused by high levels of sero-
   opposed to an excitatory neurotransmitter, the presence of           tonin and associated with agitation, restlessness, insomnia,
   which increases the probability of neuronal firing).                  tremor, nausea, vomiting, rapid heart rate, and seizures.
kava (See Piper methysticum).                                        sertraline (Zoloft) A selective serotonin reuptake inhibitor.
kava kava (See Piper methysticum).                                   SSRIs (See selective serotonin reuptake inhibitors).
kavalactones Fatlike compounds with sedative qualities               St. John’s wort (See Hypericum perforatum).
   found in Piper methysticum (kava).                                thought field therapy An alternative to psychotherapy in
LeShan An alternative therapy used to heal medical and psy-             which the practitioner helps the client tap a series of
   chological problems when the treatment provider and pa-              points on the body in order to alter thoughts.
   tient are a distance apart.                                       transducive points Specific places on the body that the client
ma huang (See ephedra).                                                 taps as part of thought field therapy.
MAO inhibitors (See monoamine oxidase inhibitors).                   tricyclic antidepressants A class of antidepressant drugs, in-
MAOIs (See monoamine oxidase inhibitors).                               cluding Elavil, Anafranil, Tofranil, and Pamelor, which
monoamine oxidase inhibitors (MAO inhibitors; MAOIs) A                  work by blocking norepinephrine reuptake, with some
   class of antidepressants (including Nardil, Marplan, Par-            blocking of serotonin reuptake.
   nate, and Deprenyl) that work by blocking the enzyme              tryptophan An amino acid from which serotonin and mela-
   that breaks down serotonin and norepinephrine.                       tonin are manufactured in the body, which was sold as an
noradrenaline (See norepinephrine).                                     over-the-counter sleep aide until an impurity in one bad
norepinephrine Also called noradrenaline; a neurotransmit-              batch caused severe medical problems and death in a num-
   ter that interacts with epinephrine to affect autonomic ac-          ber of users.
   tivity and mood.                                                  valerian (See Valerianae radix).
perturbations Hypothesized structures throughout the body            Valeriana officinalis (See Valerianae radix).
   believed by proponents of thought field therapy to contain         Valerianae radix Also called valerian, Valeriana officinalis,
   the energy that creates psychological disturbances.                  or heliotrophe; an herb with mild tranquilizing effects,
Piper methysticum Also called kava or kava kava; an herbal              sold over-the-counter to treat insomnia and mild anxiety.
   compound marketed over-the-counter for the treatment of           warfarin (Coumadin) A prescription anticoagulant (blood
                                                                        thinner) medication, available in pills or IV injection.
   anxiety and insomnia.
platelets Cell-like particles in the blood, smaller than red or
   white blood cells, which clump together and promote
   clotting.
psychotropic medications Medications used to treat mental               Because of advances in modern medicine during the
   and emotional problems, including antidepressants, an-            20th century, homeopathic and naturopathic medicine
   tipsychotics, and tranquilizers.                                  had all but vanished in the United States. However, the
Reiki (Pronounced “ray-key”) an ancient Buddhist practice            past few decades have seen a revival of alternative med-
   of manual healing therapy, used to treat both medical con-        ical treatments, with Americans making an estimated
   ditions and psychological problems.                               half-billion visits to alternative practitioners annually.
REM (rapid eye movement) sleep A stage of sleep character-           Unfortunately, most alternative treatments, although
   ized by rapid eye movements, behavioral activity, high
                                                                     promising, remain unvalidated by well-controlled sci-
   electrical activity in the brain, increased rate and depth of
                                                                     entific study at this time.
   breathing, and dreaming.
S-adenosylmethionine (SAMe) An herbal compound mar-                     Many American consumers are now seeking alterna-
   keted over-the-counter for the treatment of depression and        tive therapies for their psychological problems as well
   some medical conditions, including osteoarthritis and liver       as for their medical problems. Alternative therapies for
   disease; may affect brain levels of serotonin, noradrenaline,     psychological problems include nutritional programs
   and dopamine.                                                     for the management of mental disorders, various tech-
SAMe (See S-adenosylmethionine).                                     niques of bodywork and body alignment for clearer
                                                 Alternatives to Psychotherapy                                          35
thinking and peace of mind, aromatherapy, various                 touch, and LeShan (a distance healing technique) than in
types of touch therapy for emotional healing, magnet              controls. Studies by Schlitz and Braud in 1985 and
therapy, moving meditations such as tai chi and yoga,             Thornton in 1966 examined the claim that Reiki induces
music therapy, and various forms of prayer. Such a vast           relaxation and found that the autonomic activities of sub-
array of alternatives to psychotherapy exists that it             jects receiving Reiki did not differ significantly from
would be impossible to cover them all in detail in this           those of controls.
article. Therefore, this article will focus on two types of          No adverse effects on patients have been reported
alternative psychological treatments: technical and               with Reiki. However, no therapeutic benefits of Reiki
pharmacologic (herbal). Examples of each will be of-              have been demonstrated through well-controlled, sci-
fered.                                                            entific studies. The few studies on Reiki have generally
                                                                  been poorly designed, with such confounding variables
                                                                  as lighting, candles, and music. Although interest in
       I. TECHNICAL ALTERNATIVES                                  Reiki is growing among alternative practitioners, there
            TO PSYCHOTHERAPY                                      is no strong scientific evidence to date for its effective-
                                                                  ness, and Reiki remains unvalidated.
                        A. Reiki
                                                                         B. Thought Field Therapy (TFT)
    Reiki (pronounced “ray-key”) is an ancient Buddhist
practice of manual healing therapy that was rediscovered             Thought field therapy (TFT) is an alternative to psy-
in Japan by Mikao Usui in the mid 1800s. It has become            chotherapy used to treat depression, anxiety, phobias,
increasingly popular in the United States during the past         addictions, anger, trauma, grief, and other emotional
few decades and is used for treating heart attacks, emphy-        and mental conditions. It was developed by Roger
sema, hemorrhoids, prostate problems, varicose veins,             Callahan, Ph.D., after his reported discovery of the ex-
hiccups, nosebleeds, and various mental and emotional             istence of certain structures of active information
problems. It is based on the belief that life is dependent        (called perturbations) in the bioenergy thought field,
on a universal, nonphysical energy. Because health re-            which he believes cause psychological disorders.
quires a sustained and balanced flow of this energy                Through a long process of trial and error, Dr. Callahan
throughout the body, disturbances in that flow result in           developed TFT to diagnose and treat these perturba-
physical, emotional, and mental illnesses. The Reiki prac-        tions in the energy field.
titioner attempts to correct life energy imbalances and              Proponents of TFT view psychological change as oc-
blockages by gently resting his or her hands in specific           curring via quantum leaps rather than by a step-by-step
ways on 12 standard sites throughout the body. The prac-          linear process. In order to treat psychological prob-
titioner generally begins with the head and spends a few          lems, the TFT practitioner is able to see and feel the re-
minutes at each site, with a complete session taking an           ality of a perturbation. Once the diagnosis of a
hour or more. In some cases, the practitioner will expand         perturbation is made, the practitioner helps the client
the therapy beyond the standard 12 sites. Advanced prac-          to tap a series of “transductive points” on the body in
titioners believe themselves to be as effective even when         order to alter the structure of the thought field specific
physically absent from their patients by simply visualiz-         to the problem. Proponents of TFT believe the treat-
ing their hand movements with patients. These practi-             ment to be so powerful that it need only be used once
tioners believe that they can send spiritual energy to their      to result in significant change for a number of psycho-
patients through a process similar to prayer, and thus are        logical problems.
able to perform effective Reiki from a distance.                     Although the proponents of TFT claim that it has
    Some researchers have proposed that Reiki changes the         been proven to be more effective than psychotherapy, its
blood’s oxygen-carrying capability as shown by hemoglo-           effectiveness has not been demonstrated using well-con-
bin and hematocrit levels. However, the few studies con-          trolled scientific studies. The evidence presented is gen-
ducted to date have yielded mixed results and some of             erally anecdotal and lacks any comparison (control)
those studies showing changes in hemoglobin or hemat-             groups. For example, Leonoff in 1996 reported a study
ocrit levels actually show changes for the worse rather           in which he replicated a 1986 study by Dr. Callahan.
than for the better. One study by Wirth and Barrett in            Both studies used 68 subjects who called a radio pro-
1994 actually showed slower wound healing time in pa-             gram to receive on-the-air treatment by the researchers,
tients receiving a combination of Reiki, therapeutic              and both studies claim a 97% success rate with a 75%
36                                            Alternatives to Psychotherapy

average improvement based on clients’ reports of distress         Shapiro in 1995 theorized that EMDR utilizes the
using a 10-point rating scale. However, neither study          same brain processes as REM sleep, although she ad-
used a control group, and the comparison of the two            mits that current knowledge of neurology and neurobi-
studies by Leonoff in 1996 simply compares the use of          ology does not provide an explanation of exactly how
TFT by practitioners in 1985 to the use of TFT by prac-        EMDR works. Even though the precise impact of
titioners in 1996 without comparing TFT to any other           EMDR on the brain remains unknown, EMDR has re-
treatment modality. Therefore, TFT remains unvalidated         ceived more rigorous, scientific study than the previ-
at this time.                                                  ously mentioned alternatives to psychotherapy. Shapiro
                                                               and Forrest in 1997 cited a number of case reports and
     C. Eye Movement Desensitization                           nonrandomized studies in order to demonstrate the ef-
                                                               ficacy of EMDR. In addition to these studies, the au-
         and Reprocessing (EMDR)
                                                               thors cite 12 randomized and controlled studies that
   EMDR was first introduced in 1989 by Francine                serve to validate EMDR. Some of these studies have
Shapiro, Ph.D., and has since been taught to thousands         compared EMDR to other psychological treatment
of clinicians and has received considerable media atten-       modalities, to no-treatment controls, or to delayed
tion. It is used for the treatment of trauma and the var-      EMDR treatment, while other studies compare stan-
ious psychological symptoms that are believed to result        dard EMDR to variations of EMDR such as engendering
from traumatic experiences. EMDR practitioners use             eye movements by tracking a light bar rather than by
an eight-phase protocol to help trauma victims re-             tracking the clinician’s finger or using forced eye fixa-
process distressing thoughts and memories, which in-           tion, hand taps, and hand waving instead of the stan-
cludes using eye movements or other left-right                 dard eye movements.
stimulation:                                                      These randomized and controlled studies indicate
                                                               that EMDR is superior to other treatment modalities for
   Phase I: Client history                                     the populations studied. However, some of the differ-
  Phase II: Preparation (in which the theory is ex-            ences are small even though they are statistically signif-
            plained, expectations are set, and the             icant. They also indicate that, in general, standard
            client’s fears are addressed)                      EMDR is as effective or more effective than the varia-
 Phase III: Assessment (in which negative cogni-               tions studied. Although this research seems promising,
            tions are identified, positive cognitions           more study is needed before EMDR can be considered a
            are developed, emotions are named, and             validated treatment method. Shapiro and Forrest in
            body sensations are identified)                     1997 reported studies that indicate that EMDR is at
 Phase IV: Desensitization (in which eye movements             least as effective as other treatments, but do not state
            are utilized to reduce the client’s anxiety        whether or not any studies conducted have indicated
            about a certain situation or event)                that EMDR is less effective than other treatment modal-
  Phase V: Installation (in which a positive cogni-            ities for any conditions. Furthermore, some of the stud-
            tion is enhanced and linked to the origi-          ies reported are flawed by confounding variables, such
            nal target issue or event)                         as the secondary gains of chronic inpatient veterans re-
 Phase VI: Body scan (which focuses on any body                ceiving compensation from the VA system. Some stud-
            tension produced by the original memory            ies compare EMDR to treatment modalities unlikely to
            or the positive cognition that has been            be effective for the condition being studied, such as
            linked to it through the treatment)                biofeedback relaxation for veterans who have experi-
Phase VII: Closure (in which the client is returned            enced chronic PTSD symptoms since the Vietnam War.
            to a positive frame of mind and is deter-          The gains shown from EMDR as compared to no-treat-
            mined to be able to safely return home             ment controls may be due to the EMDR itself or to the
            before being dismissed)                            placebo effect, which is generally accepted as about
Phase VIII: Reevaluation and use of the EMDR stan-             35% in magnitude. It is unknown whether the gains
            dard protocol (in which the clinician as-          from EMDR are due to the eye movements themselves
            sesses how well the trauma has been                or to other aspects of the protocol that closely resemble
            resolved and determines whether or not             traditional psychotherapy (such as replacing negative
            the client needs any further processing)           cognitions with positive ones). Therefore, EMDR has
                                                Alternatives to Psychotherapy                                           37
some supporting evidence, but more research is                   herbal supplements are exempt from FDA control,
needed.                                                          many products sold do not contain the amount of ac-
                                                                 tive ingredient indicated on the label. Occasionally the
                                                                 products contain more of the active ingredient than in-
                                                                 dicated, while often the products contain substantially
            II. PHARMACOLOGIC                                    less of the active ingredient than the label indicates.
          (HERBAL) ALTERNATIVES                                  For this reason, research done using standardized
            TO PSYCHOTHERAPY                                     dosages of herbal remedies may not be a valid indica-
                                                                 tion of the efficacy of the unstandardized herbs avail-
   Herbal remedies have become such a major factor in            able to the American public.
American health care in recent decades that the Physi-              Most of the American public is unaware that most
cian’s Desk Reference (PDR) has had a companion volume           herbal products have side effects and interaction effects
(PDR for Herbal Medicines) updated annually since 1998.          with medications. Some of the side effects and interac-
In 1997, about 12% of Americans used herbal products,            tion effects will be discussed with each example of
compared to about 3% in 1990. Most consumers who use             herbal alternatives to psychotherapy.
herbal products do so for the management of chronic
conditions, such as psychiatric disorders (particularly                           A. St. John’s Wort
anxiety and depression).
                                                                                (Hypericum perforatum)
   Although the American public tends to equate “natu-
ral” and “herbal” with “safe,” the efficacy and safety of            St. John’s wort was used by the ancient Greeks and
these products have only recently been studied in con-           has been used in Germany for many years as a prescrip-
trolled clinical trials. These recent studies indicate that      tion drug. It has recently become one of the most com-
not all herbal supplements are safe. For example,                mon herbal products sold in the United States, with
ephedra (also known as ma huang) is an herbal ingredi-           retail sales surpassing $140 million in 1998. Its effec-
ent found in a number of weight-loss and energy-boost-           tiveness has been studied in Europe. Linde provided a
ing products available without prescription. It has              meta-analysis of 23 randomized trials in Europe, 15 of
amphetamine-like qualities and can be dangerous, par-            which compared St. John’s wort to placebo and 8 of
ticularly for people with high blood pressure or heart           which compared it to active treatments. These studies
conditions and is responsible for dozens of deaths. The          indicate no significant difference in efficacy between St.
amino acid tryptophan had been sold as an over-the-              John’s wort and tricyclic antidepressants for mild to
counter sleep aid until 1989 when the FDA banned its             moderate depression and that St. John’s wort is more ef-
sale after at least 38 people died and numerous others           ficacious than placebo. However, these studies were
were left with painful, crippling nerve damage, severe           generally short (about 6 weeks) in duration. Research
joint pain, and scarring of internal organs from an im-          comparing St. John’s wort to selective serotonin reup-
purity in a bad batch of the supplement from one man-            take inhibitors (SSRIs) is in its infancy. One recent trial
ufacturer. Recent evidence indicates that various                compared St. John’s wort to fluoxetine (Prozac) and
combinations of herbs marketed as weight-loss prod-              showed similar improvements in both groups. A clini-
ucts and labeled “Chinese herbs” can cause kidney fail-          cal trial sponsored by the National Institute of Mental
ure and death. Most likely, aristolochic acid from the           Health (NIMH) is currently under way to compare St.
Chinese herb Aristolochia fangchi (also called guang             John’s wort to sertraline (Zoloft).
fang ji) is a potent kidney toxin responsible for the re-           One study by Shelton and colleagues, which ap-
ported kidney problems and deaths from kidney failure.           peared in the April 18, 2001 issue of the Journal of the
   Since Congress passed the Dietary Supplement                  American Medical Association (JAMA), indicated that St.
Health Education Act (DSHEA) in 1994, most herbal                John’s wort is no more effective than placebo for treat-
supplements have not been regulated by the FDA.                  ing major depression. The study has gained significant
Products labeled “dietary supplement” are exempt                 media attention and has called into question previous
from FDA control, as long as they do not claim to cure           studies indicating that St. John’s wort is effective. How-
any disease. Therefore, herbal products are not sub-             ever, the recent JAMA study looked at St. John’s wort
jected to the same rigorous testing and standards as             and major depression whereas the previous studies had
over-the-counter and prescription drugs. Because most            looked at St. John’s wort for the treatment of mild or
38                                               Alternatives to Psychotherapy

moderate depression. Taken as a whole, the body of re-               The most common side effects of 5-HTP are nausea,
search available to date indicates that St. John’s wort           vomiting, diarrhea, and anorexia. Euphoria, hypoma-
may be useful for cases of mild to moderate depression,           nia, restlessness, rapid speech, anxiety, insomnia, ag-
but that it is ineffective for the treatment of severe de-        gressiveness, and agitation have also been reported. It
pression (major depression).                                      is possible that 5-HTP causes seizures in children with
   The mechanism of action of St. John’s wort is uncer-           Down syndrome, and its safety for pregnant or nursing
tain. Early studies suggested it was similar to a                 women and those with liver and kidney disease has not
monoamine oxidase (MAO) inhibitor in its action, but              been established. People with kidney disease, peptic ul-
recent data indicate it is closer to an SSRI, except that it      cers, or blood platelet disorders should not use 5-HTP.
does not affect the serotonin system in the spinal cord              There is some concern about contamination, even
and, therefore, does not produce the decrease in sexual           though the manufacture of 5-HTP is different from that
drive experienced by at least one-third of SSRI users.            of the standard tryptophan, which was banned in 1989.
Use of St. John’s wort in conjunction with MAO in-                There have been a few reports of symptoms similar to
hibitors or SSRIs is contraindicated, as the combination          those caused by contaminated tryptophan, and re-
increases SSRI-like side effects and could result in sero-        searchers have identified at least one contaminant in
tonin syndrome, a condition causing dizziness, confu-             some batches of 5-HTP.
sion, anxiety, and headaches. The syndrome is                        5-HTP interacts with MAO inhibitors, with an in-
potentially fatal.                                                crease in risk of hypertension. 5-HTP should not be
   Side effects of St. John’s wort are similar to those of        used in conjunction with tricyclic antidepressants or
SSRIs and include gastrointestinal symptoms, dizziness,           SSRIs due to the possibility of serotonin syndrome. 5-
confusion, sedation, dry mouth, photosensitivity, and in-         HTP also interacts with carbidopa (used to treat Parkin-
duction of hypomania according to Barrette, in 2000, and          son’s disease), and the combination can cause skin
PDR for Herbal Medicines in 2000. A number of drug in-            changes similar to those that occur with scleroderma.
teractions may occur with St. John’s wort. It can reduce
blood levels of the HIV drugs (such as indinavir) by more
than 50%, which may in turn lead to drug-resistant
                                                                        C. SAMe (S-adenosylmethionine)
strains of the virus, noted the University of California,            SAMe (pronounced “Sammy”) was first discovered in
Berkeley, in 2000. It reduces the effects of blood thinners       Italy in 1953. It became commercially available in Eu-
such as warfarin (Coumadin), the heart drug digoxin,              rope in 1977, and was not available in the United States
some oral contraceptives, and the immunosuppressant               until 1999. SAMe is used to treat osteoarthritis and liver
drug cyclosporine (which helps prevent organ rejection            disease, as well as depression, as noted by Gaster, and by
in transplant recipients). It increases photosensitivity          Tufts University, in 1999. SAMe’s mechanism for dealing
when used in conjunction with other photosensitizing              with depression is not understood, but some researchers
drugs.                                                            speculate that it affects brain levels of the neurotransmit-
                                                                  ters serotonin, noradrenaline, and possibly dopamine.
                                                                     More than 40 trials have been conducted to evaluate
     B. 5-HTP (5-Hydroxytryptophan)                               SAMe for the treatment of depression. However, only
   5-HTP is an herbal supplement manufactured from                five trials have tested oral forms of the herb, whereas the
the seeds of the African plant Griffonia simplicifolia. It        remaining studies have tested injectable formulations.
is metabolized into serotonin and is thought to alleviate         Only three of the five trials of oral SAMe were random-
depression by enhancing serotonin neurotransmission.              ized controlled trials. The trials that have tested in-
It is also used to treat fibromyalgia, insomnia, binge-eat-        jectable SAMe have generally shown it to be effective in
ing, attention deficit disorder, and chronic headaches.            the treatment of depression, although it is not valid to
   Studies conducted in the 1970s and early 1980s have            assume that oral SAMe is effective since it is very poorly
shown 5-HTP to be more effective than placebo in                  absorbed from the gastrointestinal tract. It is too early to
treating depression. Several small studies have com-              tell whether SAMe will prove to be a safe and effective
pared 5-HTP to standard antidepressant medications.               treatment for depression.
However, these studies have some notable flaws (small                 Stomach upset is the most common side effect re-
sample sizes, short durations, no placebo group, poor             ported with SAMe use. Enteric-coated products are less
definition of depression, and the inclusion of patients            likely to cause nausea, and are also less likely to break
with bipolar depression).                                         down in the stomach before they reach the small intestine
                                                Alternatives to Psychotherapy                                                39
where SAMe is absorbed. SAMe is contraindicated for in-          only a partial agonist it may be somewhat less effective
dividuals with bipolar disorder, as it can trigger manic         than benzodiazepines. Because GABA is an inhibitory
episodes. Those with obsessive–compulsive or addictive           neurotransmitter, stimulation of GABA receptors results
tendencies should not take SAMe, as it may worsen their          in CNS depression, noted Cummings, in 2000.
problems.                                                           Use of kava with other central nervous system de-
   Safety concerns provide compelling reasons to avoid           pressants (such as alcohol, benzodiazepines, or barbi-
using SAMe pending further research. Because the re-             turates) is contraindicated, as the interaction can
search has been very short term, it is not known                 potentiate the sedative effect and possibly lead to coma.
whether taking the herb long term could cause prob-              Use of kava with anesthetics is also contraindicated, as
lems with toxicity or carcinogenicity. Because SAMe              it may prolong the sedation time and its use is con-
raises blood levels of homocysteine, it may also raise           traindicated with antipsychotic medications due to the
the risk of coronary disease. Until it is understood how         potentiation of the sedative effects. In Parkinson’s pa-
SAMe acts on the central nervous system, it is best to           tients, it can cause tremors, muscle spasms, or other
avoid taking SAMe in conjunction with other antide-              abnormal movements and may decrease the effective-
pressants, according to Gaster in 1999.                          ness of anti-Parkinson’s medications.
   Even though SAMe’s effectiveness and safety remain
unvalidated, it is considerably more expensive than                        E. Valerian, also known as
other treatments for depression (16 times as costly as                     Heliotrope (Valerianae radix
St. John’s wort, 5 times as costly as most tricyclic anti-
                                                                             or Valeriana officinalis)
depressants, and 3 times as costly as SSRIs). SAMe can-
not be recommended at this time for the treatment of                 Valerian is an herb with mild tranquilizing effects,
depression due to its high cost, uncertain absorption,           sold over-the-counter and used to treat insomnia and
uncertain safety, and potential for inducing mania.              mild anxiety. It was the 10th most popular herb in the
                                                                 United States in 1998, whereas it was ranked 18th the
                                                                 previous year. It was originally used in ancient Greece,
     D. Kava, also known as kava kava
                                                                 and was used during World War I as a primary treat-
            (Piper methysticum)
                                                                 ment for shell shock.
   Kava is a shrublike plant from the pepper family that             Like kava, valerian likely acts as a GABA agonist to pro-
is native to the South Pacific. It has traditionally been         duce its sedative effects, noted Hardy in 1999. Several good
made into beverages, but can also be purchased in pill           placebo-controlled studies indicate that it reduces the time
form. Kava is marketed in the United States as an over-          it takes to fall asleep, but the research indicating that it im-
the-counter drug to treat anxiety and insomnia and to            proves sleep quality is very limited. The few available stud-
promote relaxation, with millions of dollars being spent         ies indicate that valerian is somewhat more effective than
annually on the herb. The effectiveness of kava has been         placebo for treating mild anxiety, but is likely ineffective
researched in placebo-controlled studies conducted in            for moderate to severe anxiety or panic disorder.
the United States and Germany. Meta-analysis of these                Valerian’s side effects include mild morning sedation
studies provides evidence that kava is more effective            and headache, although one case of serious liver toxicity
than placebo for mild to moderate anxiety, but it is not         from an over-the-counter sleep remedy containing valer-
effective for panic disorder. To date, the effectiveness of      ian has been reported. Valerian use in conjunction with
kava as compared to other antianxiety medications is             other sedative drugs (such as benzodiazepines, barbitu-
unknown. Mild gastrointestinal upset is the main side ef-        rates, or anesthetics) is contraindicated, as the interaction
fect of kava, and therapeutic doses are generally well-tol-      may potentiate the sedation. The research available to
erated. However, large doses or prolonged use can cause          date indicates that valerian may not potentiate the effects
rashes (allergic skin reactions); yellow discoloration of        of alcohol, but until more research is available it is advis-
skin, hair, and nails; weight loss; and abnormal reflexes.        able not to combine the two.
   Kava root contains kavalactones, fatlike compounds
that act as sedatives, muscle relaxants, and pain reliev-
ers. It is recognized by the FDA as being intoxicating and                           III. SUMMARY
having abuse potential. Kava most likely works on the
neurotransmitter GABA (gamma-aminobutyric acid) as                 In general, good studies demonstrating the effective-
an agonist (much like benzodiazepines), but since it is          ness of most alternatives to psychotherapy are lacking.
40                                               Alternatives to Psychotherapy

In some cases, the research is yet to be conducted. In            been demonstrated to be effective adjunct treatments
other cases, the body of available research indicates that        for various medical conditions. For example, biofeed-
the treatments are ineffective or, at best, only slightly         back has been shown to be helpful in the treatment of
more effective than placebo. However, more and more               a number of medical conditions, particularly muscle
health care dollars are being spent on these and other al-        tension headaches and Raynaud’s disease. As a result,
ternative therapies. This trend toward increased utiliza-         insurance companies are becoming increasingly will-
tion of treatments that are unverified and of dubious              ing to pay for such treatments as adjuncts to standard
scientific validity is likely due to several factors: (1) The      medical treatments.
American consumer expects modern medicine to be
able to cure every ailment and alleviate every pain.
When it does not, the consumer often turns to alterna-                    See Also the Following Articles
tive techniques. (2) The public erroneously equates “al-
                                                                  Animal-Assisted Therapy I Biofeedback I Cost
ternative” with “safe” and “natural.” At the same time,
                                                                  Effectiveness I Cultural Issues I Effectiveness of
the public is concerned about the dangerous side effects
                                                                  Psychotherapy I Eye Movement Desensitization and
that may accompany prescription medications. (3)                  Reprocessing I Online or E-Therapy
Many patients believe that managed care is limiting
their access to medical treatment and medications. In
many cases, the newer psychotropic medications are
not included on some insurance companies’ formula-
                                                                                     Further Reading
ries. Even though herbal alternatives may be costly, they                       .
                                                                  Lam, Y. W. F (2000). Pharmacology update: Efficacy and safety
are often less costly than paying out-of-pocket for non-            of herbal products as psychotherapeutic agents. Providence,
formulary medications. (4) Many consumers complain                  RI: Manisses Communications Group.
that their doctors do not really listen to them and in-           Mayo Clinic. (2000). Special report: Alternative medicine.
volve them in health care decisions. On the other hand,             Rochester, MN: Mayo Foundation for Medical Education
health food store personnel and alternative practitioners           and Research Publications.
                                                                           .
                                                                  Petter, F A. (1997). Reiki fire: New information about the ori-
are often much more willing to listen, spend time with
                                                                    gins of the Reiki power. Twin Lakes, WI: Lotus Light Publi-
patients, and offer patients the opportunity to partici-
                                                                    cations.
pate in decisions. (5) Perhaps most important, the pub-           Sachs, J. (1997). Nature’s Prozac: Natural remedies and tech-
lic is deluged with health information. Few people have             niques to rid yourself of anxiety, depression, panic attacks and
the ability to read health information critically and to            stress. Englewood Cliffs, NJ: Prentice Hall.
distinguish between good science and hype.                                   .,
                                                                  Shapiro, F & Forrest, M. S. (1997). Eye movement desensiti-
   Although research to date may not be sufficient to                zation and reprocessing: The breakthrough “eye movement”
draw conclusions about the effectiveness of many al-                therapy for overcoming anxiety, stress, and trauma. New
ternative therapies, some alternative therapies have                York: Basic Books.
                                Anger Control Therapy
                                                   Raymond W. Novaco
                                                   University of California, Irvine




    I.   Description of Treatment                                       escalation of provocation Incremental increases in the proba-
   II.   Theoretical Bases                                                 bility of anger and aggression, occurring as reciprocally
  III.   Applications and Exclusions                                       heightened antagonism in an interpersonal exchange.
  IV.    Empirical Studies                                              excitation transfer The carryover of undissipated arousal, orig-
   V.    Case Illustration                                                 inating from some prior source, to a new situation having a
  VI.    Summary                                                           new source of arousal, which then heightens the probability
         Further Reading                                                   of aggression toward that new and more proximate source.
                                                                        frustration Either a situational blocking or impeding of be-
                                                                           havior toward a goal or the subjective feeling of being
                                                                           thwarted in attempting to reach a goal.
                            GLOSSARY                                    hostility An attitudinal disposition of antagonism toward an-
                                                                           other person or social system. It represents a predisposi-
aggression Behavior intended to cause psychological or                     tion to respond with aggression under conditions of
   physical harm to someone or to a surrogate target. The be-              perceived threat.
   havior many be verbal or physical, direct or indirect.               inhibition A restraining influence on anger expression. The
anger A negatively toned emotion, subjectively experienced                 restraint may be associated with either external or internal
   as an aroused state of antagonism toward someone or                     factors.
   something perceived to be the source of an aversive event.           provocation hierarchy A set of provocation scenarios pro-
anger control The regulation of anger activation and its in-               gressively graduated in degree of anger-inducing features
   tensity, duration, and mode of expression. Regulation oc-               for the client. It is constructed by the therapist in collabo-
   curs through cognitive, somatic, and behavioral systems.                ration with the client during the early stages of treatment
anger reactivity Responding to aversive, threatening, or other             and is used in the stress inoculation procedure.
   stressful stimuli with anger reactions characterized by auto-        stress inoculation A three-phased, cognitive-behavioral ap-
   maticity of engagement, high intensity, and short latency.              proach to therapy, involving cognitive preparation/conceptu-
anger schemas Mental representations about environment–be-                 alization, skill acquisition/rehearsal, and application/
   havior relationships, entailing rules governing threatening             follow-through. Cognitive restructuring, arousal reduction,
   situations. They affect anger activation and behavioral re-             and behavioral coping skills training are the core treatment
   sponding.                                                               components. Therapist-guided, graded exposure to stressors
cathartic effect The lowering of the probability of aggression             occurs in the application phase, where the client’s enhanced
   as a function of the direct expression of aggression toward             anger control skills are engaged.
   an anger-instigator. The lowering of arousal associated              violence Seriously injurious aggressive behavior, typically
   with such catharsis is more or less immediate and can be                having some larger societal significance. The injury may be
   reversed by re-instigation.                                             immediate or delayed.



Encyclopedia of Psychotherapy                                                                          Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                           41                                                      All rights reserved.
42                                                  Anger Control Therapy

      I. DESCRIPTION OF TREATMENT                                safety concerns for the clinician and be unsettling for
                                                                 mental health professionals to engage as a treatment
     A. Topic Introduction and Definition                         focus. Although many high-anger patients present with
                                                                 a hard exterior, they can be psychologically fragile, es-
   Providing psychotherapy for persons having recur-             pecially those having histories of recurrent abuse or
rent anger problems is a challenging clinical enterprise.        trauma, or when abandonment and rejection have been
This turbulent emotion, ubiquitous in everyday life, is a        significant life themes. Because anger may be embed-
feature of a wide range of clinical disorders. It is com-        ded with other distressed emotions, accessing anger is
monly observed in various personality, psychosomatic,            often not straightforward.
and conduct disorders, in schizophrenia, in bipolar
mood disorders, in organic brain disorders, in impulse
control dysfunctions, and in a variety of conditions re-                      C. Assessment Issues
sulting from trauma. The central problematic character-             Anger treatment best proceeds from proficient anger
istic of anger in the context of such clinical conditions is     problem assessment. However, assessment itself pres-
that it is “dysregulated”—that is, its activation, expres-       ents many challenges, because of the multidimensional-
sion, and effects occur without appropriate controls.            ity of anger (cognitive, physiological, and behavioral
Anger control treatment, a cognitive-behavioral inter-           features) and because the true level of anger may be
vention, augments the client’s self-regulatory capacity. It      masked by the person in reaction to the testing situa-
aims to minimize anger frequency, intensity, and dura-           tion. In many assessment contexts, particularly forensic
tion and to moderate anger expression. It is an adjunc-          ones, people are not inclined to report that they have
tive treatment for a targeted clinical problem and thus is       high anger dispositions. Even when clients are treat-
not meant to address other or more general psychother-           ment-seeking, they may not be altogether forthcoming
apeutic needs. Clinical interventions for problems of            about their anger because an “angry person” labeling
anger seek to remedy the emotional turbulence that is            carries unflattering connotations. Effectively targeting
associated with subjective distress, detrimental effects         anger treatment, as well as ascertaining therapeutic
on personal relationships, health impairments, and the           gains, hinges on assessment proficiency, which is best
manifold harmful consequences of aggressive behavior.            done by a multimethod approach utilizing interview,
The main components of anger control treatment are               psychometric, clinical rating, and behavioral observa-
cognitive restructuring, arousal reduction, and en-              tion methods, as well as archival and physiological
hancement of behavioral skills. A key feature of its im-         methods when possible.
plementation is therapist-guided progressive exposure
to provocation, in conjunction with which anger regula-
tory coping skills are acquired.                                            D. Levels of Intervention
                                                                    Psychotherapy for anger control can occur at several
                                                                 levels of intervention: (1) General clinical care for
      B. Core Characteristics of Clients
                                                                 anger; (2) psychoeducational “anger management”
   A common characteristic of people having serious              provision, typically delivered in a group format; and
anger problems is that they resist treatment, largely due        (3) anger treatment, which is best provided on an indi-
to the functional value that they ascribe to anger in            vidual basis and may require a preparatory phase to fa-
dealing with life’s adversities. Because anger can be co-        cilitate treatment engagement. The intervention levels
mingled with many other clinical problems (such as               reflect the degree of systematization, complexity, and
personality disorder, psychoses, or substance abuse),            depth of therapeutic approach. Increased depth is asso-
getting leverage for therapeutic change can be an elu-           ciated with greater individual tailoring to client needs.
sive goal, particularly when referrals for anger treat-          Correspondingly, greater specialization in techniques
ment entail some element of coercion. Efforts to                 and in clinical supervision is required at higher levels.
achieve clinical change are challenged by the adaptive
functions of anger as a normal emotion, such that it is
                                                                         E. Anger Control Treatment:
not easily relinquished. Anger is often entrenched in
personal identity and may be derivative of a traumatic
                                                                        A Stress Inoculation Approach
life history. Because anger activation may be a precur-            Cognitive-behavioral anger treatment targets endur-
sor of aggressive behavior, while being viewed as a              ing change in cognitive, arousal, and behavioral sys-
salient clinical need, it may at the same time present           tems. It centrally involves cognitive restructuring and
                                                  Anger Control Therapy                                            43
the acquisition of arousal reduction and behavioral            to be intensified or attenuated in potency. Prior to the
coping skills, achieved through changing valuations of         presentation of hierarchy items, whether in imaginal or
anger and augmenting self-monitoring capacity. Be-             role-play mode, anger control coping is rehearsed, and
cause it addresses anger as grounded and embedded in           arousal reduction is induced through deep breathing
aversive and often traumatic life experiences, it entails      and muscle relaxation. Successful completion of a hier-
the evocation of distressed emotions (e.g., fear and sad-      archy item occurs when the client indicates little or no
ness) as well as anger. Therapeutic work centrally in-         anger to the scene and can envision or enact effective
volves the learning of new modes of responding to cues         coping in dealing with the provocation.
previously evocative of anger in the context of relating          Following the completion of the hierarchy, an effort
to the therapist (“transference”), and it periodically         is made to anticipate circumstances in the client’s life
elicits negative sentiment on the part of the therapist to     that could be anger-provoking and the obstacles to
the frustrating, resistive, and unappreciative behavior        anger control that might arise. This is done as a re-
of the client (“countertransference”). Anger treatment         lapse prevention effort, especially as people having
that has followed a “stress inoculation” approach uti-         anger difficulties are often without adequate support-
lizes provocation hierarchy exposure. The inoculation          ive relationships to provide reinforcement for anger
metaphor is associated with the therapist-guided, pro-         control. Follow-up or booster sessions are typically
gressive exposure to provocation stimuli. This occurs          arranged to provide support, to ascertain what coping
in vitro through imaginal and role-play provocations in        skills have proven to be most efficacious, and to boost
the clinic, and in vivo through planned testing of cop-        treatment in areas in need of further work. Because of
ing skills in anger-inducing situations identified by the       the reputations acquired by high-anger people, the re-
client’s hierarchy.                                            actions of others to them can be slow to change. This
   Stress inoculation for anger control involves the fol-      can lead to relapse and requires therapeutic attention
lowing key components: (1) Client education about              at follow-up.
anger, stress, and aggression; (2) self-monitoring of
anger frequency, intensity, and situational triggers; (3)
                                                                          F. Treatment Preparatory
construction of a personal anger provocation hierarchy,
                                                                                Phase Needed
created from the self-monitoring data and used for the
practice and testing of coping skills; (4) arousal reduc-         Some seriously angry clients may be quite am-
tion techniques of progressive muscle relaxation, breath-      bivalent about earnestly engaging in assessment and
ing-focused relaxation, and guided imagery training; (5)       treatment, and in some clinical service contexts, par-
cognitive restructuring of anger schemas by altering           ticularly forensic settings, angry patients may be very
attentional focus, modifying appraisals, and using self-       guarded about self-disclosure. Because of the instru-
instruction; (6) training behavioral coping skills in com-     mental value of anger and aggression, many clients do
munication, diplomacy, respectful assertiveness, and           not readily recognize the personal costs that their
strategic withdrawal, as modeled and rehearsed with the        anger routines incur; because of the embeddedness of
therapist; and (7) practicing the cognitive, arousal regu-     anger in long-standing psychological distress, there is
latory, and behavioral coping skills while visualizing and     inertia to overcome in motivating change efforts. In
role-playing progressively more intense anger-arousing         such circumstances, a treatment “preparatory phase” is
scenes from the personal hierarchies.                          implemented, involving a block of five to seven ses-
   Provocation is simulated in the therapeutic context         sions, varying with client competence and motivation.
by imagination and role-play of anger incidents from           The aim is to foster engagement and motivation, while
the hierarchy scenarios, produced by the collaborative         conducting further assessment and developing the
work of client and therapist. The scenarios incorporate        core competencies necessary for treatment, such as
wording that captures the client’s perceptual sensitivi-       emotion identification, self-monitoring, communica-
ties on provoking elements, such as the antagonist’s           tion about anger experiences, and arousal reduction. It
tone of voice or nuances of facial expression. Each sce-       serves to build trust in the therapist and the treatment
nario ends with provocative aspects of the situation           program, providing an atmosphere conducive to per-
(i.e., not providing the client’s reaction), so that it        sonal disclosure and collaboration. Since the prepara-
serves as a stimulus scene. The therapist directs this         tory phase can be pitched to the client as a “trial
graduated exposure to provocation and knows the                period,” its conclusion then leads to a more explicit
moderating variables that will exacerbate or buffer the        and informed choice by the client about starting treat-
magnitude of the anger reaction, should the scene need         ment proper.
44                                                Anger Control Therapy

           II. THEORETICAL BASES                                           B. Anger and Cognition
                                                                  Central to therapeutic prescriptions for anger control
              A. Anger and Threat
                                                               is the idea that emotion is a function of cognitive ap-
   The conception of anger as a product of threat per-         praisal. That is, anger is produced by the meaning that
ceptions, as having confirmatory bias characteristics           events have and the resources we have for dealing with
(i.e., the perception of events is biased toward fit with       them, rather than by the objective properties of the
existing anger schemas), as being primed by aversive           events. Important work in this regard was done by
precursors, and as having social distancing effects (i.e.,     Lazarus on appraisal processes and on stress coping
expressing anger keeps people away) can be found in            styles, yet there is dispute about how pivotal is appraisal
the writings of Lucius Seneca, who was Nero’s tutor in         in the activation of anger. Berkowitz alternatively asserts
first-century Rome. Seneca was the first to write system-        that aversive events trigger basic associations to aggres-
atically about anger control. Like other Stoic philoso-        sion-related tendencies as a “primitive” or “lower order”
phers who negate the value of emotions, his view of            processing, which is then paralleled by anger in associa-
anger was almost exclusively negative. Although his            tion. “Higher order” processing, such as appraisal, is
idea of anger control was largely that of suppression,         then subsequent to the rudimentary reactions, and anger
Seneca recognized the powerful role of cognition as a          can be elaborated by the appraisal. Similarly, Beck has
determinant of anger, advocated cognitive shift and re-        conjectured that anger derives from “primitive” process-
framing to minimize anger, and saw the merit of a calm         ing in defense against threat, in which mode information
                                                               is rapidly compartmentalized. Negative biases and over-
response to outrageous insult. However, he discounted
                                                               generalization lead to information-processing errors and
the functional value of anger, which thereby led him to
                                                               anger activation. Appraisal processing (activation of be-
miss the principle of regulation.
                                                               liefs and interpretations) may then follow this primal
   Since the writings of Charles Darwin, William James,
                                                               thinking mode. What Beck adds is that automatic
and Walter B. Cannon, anger has been viewed in terms
                                                               thoughts are activated in the primal mode and that these
of the engagement of the organism’s survival systems in
                                                               are the roots of emotional distress.
response to threat and the interplay of cognitive,
                                                                  This differentiation between “lower order” and
physiological, and behavioral components. It is an ele-
                                                               “higher order” processing may otherwise be viewed as
mentary Darwinian notion that the adaptive value of a          a distinction between “automatic” versus “controlled”
characteristic is entailed by its fitness for the environ-      operations. Sometimes anger occurs as a fast-triggered,
ment; if the environment changes, that characteristic          reflexive response, while other times it results from de-
may lose its adaptive value, and the organism must             liberate attention, extended search, and conscious re-
adjust. The activation of anger may usefully serve to          view. There is nothing necessarily “primitive” about
engage aggression in combat and to overcome fear, but          automaticity in anger responding, as anger schemas
in most everyday contexts, anger is often maladaptive.         and aggressive scripts, which are acquired through so-
   Many theories of emotion have enlarged upon the             cial learning, can produce rapid reaction to provocation
Darwinian view of emotions as reactions to basic sur-          stimuli. Furthermore, central cognitive processes can
vival problems created by the environment and upon             override reflexive responding to aversive stimulation.
Cannon’s idea that internal changes prepare the body           Otherwise we would be very angry on most trips to the
for fight or flight behavior. Thus, emotion has com-             dentist, and professional boxers in the ring would be in
monly been viewed as an action disposition. Some con-          a continuous state of rage.
temporary theorists postulate that emotion is controlled          Social information processing models of aggressive
by appetitive and aversive motive systems in the brain,        behavior, such as that of Huesmann, view the human
with the amygdala serving as a key site for the aversive       mind as analogous to a computer. Anger schemas are
motivational system, and neurobiological mechanisms            thus understood as macro knowledge structures, en-
associated with amygdala involvement in aversive emo-          coded in memory, that filter our perceptions and are
tion and trauma are being studied in various laborato-         used to make inferences. Aggressive scripts are subrou-
ries. Most generally, when people are exposed to stimuli       tines that serve as guides for behavior, laying out the
signifying present danger or reminders of trauma, they         sequence of moves or events thought to be likely to
are primed for anger reactions. Anger is intrinsically         occur and the behavior thought to be possible or ap-
connected to threat perception.                                propriate for a certain situation.
                                                     Anger Control Therapy                                             45
   The main thrust of such conceptions is that anger                          D. Person–Environment
and its associated behavior are cognitively mediated.                          Context and Systems
Correspondingly, anger control interventions target the
way in which people process information, remember                    Anger and anger control difficulties should be un-
their experiences, and cognitively orient to new situa-           derstood contextually. This assumes that recurrent
tions of stress or challenge. Therapeutic change of               anger is grounded in long-term adaptations to inter-
schemas linked to anger prevents the occurrence of                nal and external environmental demands, involving a
anger, and the self-regulation of anger once activated is         range of systems from the biological to the sociocultu-
effected by controlled use of cognitive self-control tech-        ral. The adaptive functions of anger affect the social
niques, such as calming self-instructions and relaxation          and physical environmental systems in which the per-
imagery, combined with other arousal reduction and                son has membership. Anger experiences are embed-
behavioral coping strategies.                                     ded or nested within overlapping systems, such as the
                                                                  work setting, the work organization, the regional
            C. Cognition, Arousal,                                economy, and the sociocultural value structure. Anger
          and Behavior Reciprocities                              determinants, anger experiences, and anger sequelae
                                                                  are interdependent.
   Intrapsychic, dispositional systems are the principal             The interrelatedness of system components provides
focus of psychotherapy, and, in that regard, anger has            for positive and negative feedback loops. When a system
three main subsystems or domains: cognitive, physiolog-           moves away from equilibrium, negative feedback loops
ical, and behavioral. Cognitive dispositions for anger in-
                                                                  serve to counteract the deviation, such as when the self-
clude knowledge structures, such as expectations and
                                                                  monitoring anger reactions prompt deep breathing or
beliefs, and appraisal processes, which are schematically
                                                                  cognitive reappraisal to achieve anger control. In con-
organized as mental representations about environ-
                                                                  trast, anger reactions can be augmented by positive feed-
ment–behavior relationships entailing rules governing
                                                                  back, which is a deviation amplification effect. Anger
threatening situations. Arousal or physiological disposi-
                                                                  displays in a situation of conflict tend to evoke anger
tions for anger include high hormone levels (neurotrans-
                                                                  and aggression in response, which then justify the origi-
mitters) and low stimulus thresholds for the activation of
                                                                  nal anger and increase the probability of heightened an-
arousal. Anger is marked by physiological activation in
                                                                  tagonism. Such anger–aggression escalation effects are
the cardiovascular, endocrine, and limbic systems, and by
tension in the skeletal musculature. Behavioral disposi-          well-known in conflict scenarios, whether interpersonal
tions include conditioned and observably learned reper-           or international.
toires of anger-expressive behavior, including aggression            Intervention proceeding from a contextual model
but also avoidance behavior. Implicit in the cognitive la-        examines environmental, interpersonal, and disposi-
beling of anger is an inclination to act antagonistically to-     tional subsystems that shape anger reactions. Al-
ward the source of the provocation. However, an avoidant          though recurrent anger is often a product of long-term
style of responding, found in personality and psychoso-           exposure to adverse conditions or to acute trauma, it
matic disorders, can foment anger by leaving the provo-           is nevertheless the case that anger is a product of agen-
cation unchanged or exacerbated.                                  tic behavior. People who select high-conflict settings
   Thus, it can be seen that these dispositional subsys-          or recurrently inhabit high-stress environments set
tems are highly interactive or interdependent. Anger-             the stage for their anger experiences. Those who are
linked appraisals influence arousal levels, high arousal           habitually hostile create systemic conditions that
activates aggression and overrides inhibition, and an-            fuel continued anger responding that is resistant to
tagonistic behavior escalates aversive events and shapes          change. As anger schemas solidify, anger is evoked
anger schemas and scripts for anger episodes as behav-            with considerable automaticity in reaction to minimal
ioral routines are encoded. In turn, the personal dispo-          threat cues. Aggressive scripts that program antago-
sitional system interfaces with the environmental, such           nistic behavior, which exacerbates anger difficulties,
as when anger and aggression drive away pacific peo-               are socially and contextually learned. Focus on in-
ple, leaving one with angry and aggressive companions,            trapsychic variables is transparently inadequate when
who not only incite anger but from whom one contin-               the person remains immersed in anger-engendering
ues to learn anger responding and anger-engendering               contexts. Coordinated efforts of a multidisciplinary
appraisals, which further heighten arousal.                       treatment team may be required.
46                                               Anger Control Therapy

               III. APPLICATIONS                              behavioral interventions produce therapeutic gains in
               AND EXCLUSIONS                                 anger control. However, there have been few random-
                                                              ized control studies with seriously disordered patients.
   Anger control therapy is an adjunctive treatment.          Such studies have more commonly been done with col-
Across categories of clients, the key issues regarding        lege student volunteers, selected as treatment recipi-
appropriateness for this therapy are (1) The extent to        ents by upper quartile scores on self-reported trait
which the person has an anger regulatory problem, im-         anger, by having expressed interest in counseling for
plying that acquisition or augmentation of anger con-         anger management, and by volunteering over the tele-
trol capacity would reduce psychological distress, the        phone. Such sample inclusion criteria do not reflect the
probability of aggression or other offending behavior,        clinical needs of the angry patients seen by mental
or a physical health problem, such as high blood pres-        health service providers in community and institu-
sure; (2) whether the person does recognize, or can be        tional settings. Existing meta-analytic reviews of treat-
induced to see, the costs of his or her anger and aggres-     ment efficacy are overloaded with college student
sion routines and is thus motivated to engage in treat-       studies and fail to include case study reports and multi-
ment; and (3) whether the person can sit and attend for       ple baseline studies, which have typically involved real
approximately 45 minutes. The latter criterion applies        patients with serious problems. Nevertheless, statistical
especially to hospitalized patients. The stress inocula-      computations in reviews across dozens of controlled
tion approach to anger has been successfully applied to       studies have found medium effect sizes for anger treat-
institutionalized mentally disordered (schizophrenia          ments, indicating that the large majority of treated par-
and affective disorders) and intellectual disabled per-       ticipants were improved.
sons (mild to borderline). Because resolution on the             Cognitive-behavior therapy approaches that have
issue of treatment engagement is often elusive, an            not followed the stress inoculation framework have
anger treatment “preparatory phase” has been devel-           produced significant treatment gains, such as those by
oped and implemented in work with forensic patients.          Deffenbacher and his colleagues using cognitive and
Such preparatory work would also be appropriate for           relaxation methods with college student volunteers
persons who have anger dysregulation in conjunction           without demonstrable clinical pathology or violence
with trauma.                                                  history. However, such treatment study participants do
   People with violent behavior problems are often re-        not reflect the clinical needs of the angry patients seen
ferred for anger treatment (e.g., incarcerated offenders      by mental health service providers in community and
and spousal abusers or enraged drivers in the commu-          institutional settings. In contrast to college student vol-
nity). However, anger treatment is not indicated for          unteer studies, a controlled anger treatment trial with
those whose violent behavior is not emotionally medi-         seriously disordered Vietnam veterans by Chemtob,
ated, whose violent behavior fits their short-term or          Novaco, Hamada, and Gross in 1997, which was
long-term goals, or whose violence is anger mediated          missed in the Beck and Fernandez meta-analysis in
but not acknowledged. Little is known about the effi-          1998, obtained significant treatment effects on multiple
cacy of cognitive-behavior therapy anger treatment            measures of anger reactions and anger control for the
with psychopaths, but it is doubtful that it would be         stress inoculation anger treatment, compared to a mul-
suitable. As well, persons who are acutely psychotic or       timodal, routine care control treatment condition. The
whose delusions significantly interfere with daily func-       anger control treatment gains with these severe post-
tioning are not suitable candidates for this self-regula-     traumatic stress disorder patients, who had had in-
tory treatment. Persons with substance abuse disorders        tense, recurrent postwar problems with anger and
also require prior treatment to engage in anger therapy.      aggressive behavior, were maintained at 18-month fol-
Successful case applications are given later.                 low-up. Other control group studies involving success-
                                                              ful outcomes for the modified stress inoculation
                                                              approach to anger treatment with clinical populations
                                                              have included adolescents in residential care, adoles-
           IV. EMPIRICAL STUDIES                              cent offenders, forensic patients, and mentally retarded
                                                              adults. Exemplary work on anger control with adoles-
  Research on anger treatment lags substantially be-          cents has been done by Feindler and her colleagues.
hind that for problems of depression and anxiety, yet            Multiple case studies involving a variety of serious
there is convergent evidence that various cognitive-          clinical disorders have provided empirical support for
                                                 Anger Control Therapy                                               47
the efficacy of cognitive-behavioral anger treatment           saulted one of the staff, so badly that this led to his ad-
and the stress inoculation approach. These include a          mission to a maximum security hospital.
hospitalized depressed patient, child abusing parents,           There, his psychotic symptoms soon remitted, but he
chronically aggressive patients, an emotionally dis-          was reported to be demanding and antiauthoritarian,
turbed boy, a brain damaged patient, mentally handi-          continually challenging the rules and reacting aggres-
capped patients, adolescents in residential treatment,        sively to any perceived threat to his self-image. A trans-
and institutionalized forensic patients.                      fer to a local hospital was unsuccessful due to his
   Brief cognitive-behavioral therapy “anger manage-          aggressive, demanding manner and drug misuse. He
ment” has been successfully used in prisons, often de-        struggled to cope with his readmission and maintained
livered in group format, varying from 3 to 16 sessions        an antiestablishment attitude. He made frequent
across studies. However, outcome evaluation assess-           threats toward staff and was physically assaultive. Mak-
ments in these prison-based studies have been thin,           ing little progress, he made a serious attempt at suicide,
and results of efficacy have been uneven. In this regard,      which was related to despair at his continued deten-
the treatment engagement issues highlighted earlier are       tion. When under stress, his positive psychotic symp-
most relevant, and the interventions used have not            toms could emerge. His close relationships having
been firmly based in a designated treatment protocol.          disintegrated, he was very worried about future inti-
Because the through-put client service needs of institu-      mate relationships.
tions and community agencies are formidable, greater
attention needs to be given to the development of
group-based intervention for anger.
                                                                         B. Treatment Application
                                                                 Mr. A received anger treatment by staff psycholo-
                                                              gists. He was happy to attend sessions but initially
                                                              found it difficult to engage in tasks. He was anxious
            V. CASE ILLUSTRATION
                                                              about being not listened to and was resistant to being
                                                              given advice. He often refused to participate, argued his
              A. Case Description
                                                              own point, talked on a tangent, or reduced everything
   Mr. A is a man in his thirties, who received anger         to a joke. He was insistent that he should not be rushed
treatment in a forensic hospital. He had a highly dys-        and feared being overwhelmed. Establishing a support-
functional home background. He was truant from                ive relationship and a sensitive pacing of therapy was
school and reported abnormal psychological experi-            vital to engagement. As he came to view his therapists
ences, resulting in the involvement of the psychiatric        as being nonjudgmental and working in his interests,
services. In his teens, he developed a substance abuse        he became less defensive and more willing to complete
problem and associated with a delinquent peer group           tasks such as anger diaries and hierarchical inoculation
that encouraged a violent presentation. Persistent petty      exercises. As treatment progressed, he became more re-
theft associated with substance abuse and aggression          silient to provocation and less likely to conclude that
led to placement in secure facilities. There, the experi-     others were personally attacking him. He found alter-
ence of both using violence and being bullied had a           native ways of viewing situations that previously had
profound effect on him.                                       initiated angry attempts to restore his self-esteem. He
   He married and had a child, but his wife left him          became more aware of his heightened level of physio-
while he was serving a short prison sentence. Follow-         logical arousal in problematic situations and used ten-
ing a period of homelessness, he was imprisoned for as-       sion reduction methods, including relaxation and
sault. He was diagnosed with schizophrenia and while          taking time-outs to create social distance from provok-
he resisted this, he would allude to having a special         ing events. He learned to approach staff to discuss mat-
destiny after an encounter with extraterrestrials who         ters of dispute and received support from his peers for
had given him the power to benefit mankind. He was             anger control.
subsequently transferred to a psychiatric hospital,              Illustrative incidents: (1) Another patient accused Mr.
where he made a number of attacks on staff. He was ul-        A of not repaying a debt. As this was said in public, Mr.
timately transferred to community accommodation,              A thought this was a deliberate attempt to humiliate
but he was ejected for theft and noncompliance. He            him and being angry, wanted to show that he was not
was readmitted to a local hospital, following arrest for      someone “to be trifled with.” However, he managed to
reckless damage and police assault. He then again as-         stay calm and avoid violence; instead he responded in a
48                                                 Anger Control Therapy

way that minimized loss of face and reminded himself            Training in self-monitoring, cognitive reframing, arousal
of the negative consequences of physical violence. Later,       reduction, and behavioral coping skills are the essential
he reassessed the situation, reasoning that the other pa-       components of the treatment. Some clients require a
tient was struggling with a life sentence for murder and        preparatory phase for treatment engagement.
had been picking on others, not just targeting him. Dis-
cussing the event with friends, they reinforced his view
and reassured him that they did not believe the accusa-                 See Also the Following Articles
tion. (2) Having been recommended for transfer to a             Arousal Training I Beck Therapy Approach I Multimodal
lower security hospital, a visit to that local hospital was     Behavior Therapy I Post-Traumatic Stress Disorder
arranged. One hour before leaving for his visit, it was
cancelled because of events at the local hospital. Ini-
tially he was convinced that there was a sinister motive,                          Further Reading
feeling that the staff were trying to renege on the agree-      Beck, A. T. (1999). Prisoners of hate: The cognitive basis of
ment. He became angry. However, he used arousal re-                anger, hostility, and violence. New York: Harper Collins.
duction techniques, and had a discussion with staff,            Beck, R., & Fernandez, E. (1998). Cognitive behavior ther-
who rearranged the visit. Staff remarked that he listened          apy in the treatment of anger: A meta-analysis. Cognitive
to their explanation and trusted them to resolve the sit-          Therapy and Research, 22, 63–75.
uation, rather than behave self-destructively.                  Berkowitz, L. (1993). Aggression: Its causes, consequences, and
                                                                   control. New York: McGraw-Hill.
                                                                Chemtob, C. M., Novaco, R. W., Hamada, R., & Gross, D.
      C. Treatment Gains and Transfer                              (1997). Cognitive-behavioral treatment for severe anger in
                                                                   posttraumatic stress disorder. Journal of Consulting and
   Level of care staff observed that Mr. A generally
                                                                   Clinical Psychology, 65, 184–189.
began to take others’ perspectives into account, and his
                                                                Feindler, E. L., & Ecton, R. B. (1986). Adolescent anger control:
psychiatrist reported that he was less impatient, less in-
                                                                   Cognitive therapy techniques. New York: Pergamon Press.
stantly demanding, and better able to listen and to dis-        Huesmann, L. R. (1998). The role of social information pro-
cuss issues in a constructive manner. His gains in anger           cessing and cognitive schema in the acquisition and main-
control led to a recommendation for transfer to his                tenance of habitual aggressive behavior. In R. Geen & E.
local hospital, and staff there reported being impressed           Donnerstein (Eds.), Human aggression: Theories, research,
with what they felt was a positive change in his presen-           and implications for social policy (pp. 73–109). San Diego,
tation. His self-reported improvement in anger control             CA: Academic Press.
and progress through the provocation hierarchy in                       .
                                                                Lang, P J. (1995). The emotion probe: Studies of motivation
treatment sessions thus received validation from ward              and attention. American Psychologist, 50, 372–385.
staff observations of his behavior and by the judgment          Lazarus, R. S. (1991). Emotion and adaptation. Oxford: Ox-
of his attending psychiatrist who arranged the transfer            ford University Press.
to a lower security hospital.                                   Meichenbaum, D. (1985). Stress inoculation training. New
                                                                   York: Pergamon Press.
                                                                Novaco, R. W. (1986). Anger as a clinical and social problem.
                                                                   In R. Blanchard & C. Blanchard (Eds.), Advances in the study
                  VI. SUMMARY                                      of aggression, Vol 2. (pp. 1–67). New York: Academic Press.
                                                                Novaco, R. W. (1997). Remediating anger and aggression
   Anger control therapy is a cognitive-behavioral treat-          with violent offenders. Legal and Criminological Psychol-
ment. It aims to augment the regulation of anger that has          ogy, 2, 77–88.
become problematic in frequency, intensity, duration, and       Novaco, R. W., & Chemtob, C. M. (1998). Anger and trauma:
mode of expression. In its fullest form of intervention,           Conceptualization, assessment, and treatment. In V. M. Fol-
it utilizes a “stress inoculation” approach, the heart of                                  .
                                                                   lette, J. I. Ruzek, & F R. Abueg (Eds.), Cognitive behavioral
which involves therapist-guided, progressive exposure              therapies for trauma (pp. 162–190). New York: Guilford.
to provocations in the clinic and in vivo, in conjunction       Siegman, A. W., & Smith, T. W. (1994). Anger, hostility, and
with which coping skills are modeled and rehearsed.                the heart. Hillsdale, NJ: Erlbaum.
                                Animal-Assisted Therapy
                                                       Aubrey H. Fine
                                                California State Polytechnic University




    I.   Description of Treatment                                         Florence Nightingale in Notes on Nursing stated that
   II.   Theoretical Bases                                             a small pet animal was an excellent companion for the
  III.   Empirical Studies                                             sick. Her impressions in the mid-ninteenth century
  IV.    Suggestions for Clinical Application                          seemed to accurately represent how animals could be
   V.    Summary                                                       supportive to the physical and mental health of indi-
         Further Reading
                                                                       viduals. Her position represents the impressions of var-
                                                                       ious health care professionals over the past century and
                                                                       a half. Nevertheless, it has been the seminal work of
                            GLOSSARY                                   Boris Levinson which many have considered to provide
                                                                       one of the earliest published papers highlighting the
animal-assisted activities Therapy that involves animals vis-
                                                                       therapeutic value of animals. Levinson’s first article was
  iting people for motivational and recreational benefits to
  enhance quality of life. The same activity can be repeated           entitled “The Dog as a Co-Therapist” and was pub-
  by the facilitator with the same or different people, unlike         lished in Mental Hygiene in 1962. His initial article was
  the therapeutic intervention that is tailored to the specific         met with cynicism and skepticism by many of his col-
  person.                                                              leagues. However, Levinson genuinely believed that an-
animal-assisted therapy A goal-oriented intervention in                imals could make a major contribution to the
  which an animal meeting specific criteria is an integral part         therapeutic process.
  of the treatment process. This service is delivered by a                Although some strides have been made in develop-
  health or human service professional working within the              ing concepts in animal–human relationships, there
  scope of his or her professional role.                               continues to be limited empirical support and limited
                                                                       research validating the overall effectiveness of this ap-
                                                                       proach. Many researchers point out that although the
         I. DESCRIPTION OF TREATMENT                                   utilization of animals may be highly appealing, the ev-
                                                                       idence that a patient has enjoyed an interaction with
   Louis Sabin once stated that “No matter how little                  an animal does not imply that the procedure is thera-
money and how few possessions you own, having a dog                    peutic. It appears that the biggest challenge facing ad-
makes you rich.” Being rich should not only ecompass                   vocates of animal-assisted therapy who claim that it
physical resources, but also the joy and love from being               improves outcomes is the need for documentation.
wanted and appreciated. Animals appear to demon-                       The author in a previous writing suggested that a
strate great compassion for others and enhance the                     concentrated stronger effort is needed in promoting
quality of life of their human counterparts.                           more sound empirical investigations demonstrating


Encyclopedia of Psychotherapy                                                                     Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                          49                                                  All rights reserved.
50                                               Animal-Assisted Therapy

the therapeutic utility of animals in various clinical            The author in his application of AAT in his work
settings. He suggested that the investigators may want         with children has also found that his clients seemed to
to study what populations animal-assisted therapy              benefit from the observations seen between the animal
(AAT) are effective with and under what conditions             and the therapist. The most common response pertains
animal-assisted activities (AAA) or AAT are the most           to the interaction with the animals and how some
valuable. Furthermore, practitioners must pay atten-           clients compare these interactions with their own
tion to the need for program evaluation and documen-           child/parent relationships (since most of his clients are
tation. These efforts will assist the scientific               children and their parents). Other clients comment on
community with the needed research priorities.                 how well the animals are treated, including the ele-
   In September 1987, the National Institutes of               ments of compassion, consistency, firmness, and love.
Health held a workshop entitled Health Benefits of             These vicarious observations can be utilized for the
Pets. Data from the proceedings highlighted some sci-          purposes of teaching skills and vicarious learning.
entific evidence that pet ownership appeared to corre-
late with improvements in quality of life. Results from
the meeting also pointed out that attachments to ani-              A. The Therapeutic Environment—
mals might also be an important dimension in study-                      Animals as an Aspect
ing those who have experienced or are experiencing                         of Milieu Therapy
reduced social contacts with people (e.g., the elderly
and isolated children). These meetings appeared to                One of the most valued aspects of having animals as
act as a catalyst for the development of numerous ani-         part of a therapeutic alliance appears to be related to
mal visiting programs (sponsored by the various hu-            their impact on altering the therapeutic environment.
mane societies) for residents in long-term facilities.         This assumption has been strongly advocated by this
These early programs were considered pleasant diver-           writer in numerous previous publications. The as-
sionary activities. They were welcomed by adminis-             sumption has also been supported by Alan Beck who
trators as long as the program didn’t pose any risks to        also believed that animals seemed to have the capacity
patient health and safety.                                     to modify a person’s environment. In most cases, pres-
   It appears that the greatest benefit an animal brings        ence of an animal appears to modify the perceived envi-
to a therapeutic setting is its ability to enhance the re-     ronment and make it more friendly and comfortable to
lationship between therapist and client. Its presence          incoming clients. Herbert Sklar suggests that develop-
seems to make the client more comfortable and at ease.         ment of an effective therapeutic alliance may actually
Phil Arkow suggested that the animal may act as a cat-         begin with the creation of a proper therapeutic envi-
alyst for the conversation between the therapist and           ronment. It appears that the client’s readiness for psy-
the client. He called this process a rippling effect. Oth-     chotherapy could be disturbed by the simplicity of a
ers, such as Samuel Corson and Elizabeth Corson, call          clinic’s decor and perhaps by its disorder.
this process a social lubricant. The presence of the an-          It seems obvious that living beings could also be uti-
imal allows the client a sense of comfort, which then          lized to complement the work environment by making
promotes rapport in the therapeutic relationship.              it more appealing and relaxing. Of utmost value is that
Studies reported in the literature point out that a ther-      animals appear to bring a certain sense of security and
apist who conducts therapy with an animal being pres-          warmth into the environment. Alan Beck and his asso-
ent may appear less threatening, and, consequently,            ciates conducted a study in Haverford, Pennsylvania,
the client may be more willing to reveal him/herself.          where they hypothesized that animals would alter the
Some clinicians report that in interviews in the pres-         therapeutic environment and make it less threatening
ence of their dogs, children appeared more relaxed and         to patients with various mental illnesses. The patients
seemed more cooperative during their visit. The find-           (who met in a room containing birds) attended ses-
ings appear to conclude that the dogs serve to reduce          sions more faithfully and became more active partici-
the initial tension and assisted in developing an atmos-       pants in comparison to a control group. In addition,
phere of warmth. The animals appear to help many               the researchers found a reduction in hostility scores
clients overcome their anxiety about going into ther-          (from the Brief Psychiatric Rating Scale) in the clients
apy. Many therapy animals, especially dogs, are more           within the experimental milieu.
than willing to receive a client in a warm and affec-             A variety of researchers have looked at animals
tionate manner.                                                and their apparent impact on reducing stress in an
                                                   Animal-Assisted Therapy                                                  51
environment. For example, Aaron Katcher, Arline                                         TABLE 1
Segal, and Alan Beck reported, in their study on anxi-            Animal-Assisted Therapy from a Life-Stage Perspective
ety and discomfort before and during dental surgery,
that subjects viewing the aquarium appeared more                 Suggested developmental goals and treatment purposes
comfortable and less anxious than those subjects in a              for children
control group not viewing an aquarium. Watching a                Suggestion 1. Within the first series of life stages, the pri-
school of fish can be quite relaxing for some. With                mary goals to be achieved pertain to a child’s need to feel
proper lighting and an attractively designed tank,                 loved, as well as developing a sense of industry and com-
clients can feel more at ease when they enter an office            petence. In a practical sense, animals can assist the clini-
or while in therapy.                                               cian in promoting unconditional acceptance. The animal’s
                                                                   presence in therapy (as discussed previously) may assist a
                                                                   child in learning to trust. Furthermore, the animal may
   B. Incorporating Theory in Practice:                            also help the clinician demonstrate to the child that he is
     Animal-Assisted Therapy from a                                worth loving.
          Life Stage Perspective                                 Suggestion 2. The animal-assisted therapy can eventually go
                                                                   beyond the office visit. A clinician may suggest to a family
   A clinician’s theoretical orientation will have a strong        the value of having a pet within the home. The animal
bearing on the incorporation of animals within his or              may help a child develop a sense of responsibility as well
her therapeutic approach. An explanation that seems to             as importance in life.
naturally align itself is Erikson’s theoretical orientation.     Suggested developmental goals and treatment purposes
Erikson views development as a passage through a series            for adolescence
of psychosocial stages, each with its particular goals,          Suggestion 1. A clinician may find an animal’s presence valu-
concerns, and needs. Although the themes may repeat                able in making the teen feel more at ease during his or her
during a life cycle, Erikson noted that certain life con-          visit. The teen may be more willing to take down some of
cerns were more relevant during specific eras. For exam-            the barriers, if she or he feels more comfortable. Further-
ple, as people age and experience new situations, they             more, although a teen may project the need to be adult-
confront a series of psychosocial challenges. Aubrey               like, the teen may appreciate the free spirit of an animal.
                                                                   The comfort the youth may receive may allow him or her
Fine, in an article written on AAT in psychotherapy in
                                                                   to feel more appreciated.
the Handbook on Animal Assisted Therapy, recommended
that clinicians should consider the various eight stages         Suggested developmental goals and treatment purposes
of psychosocial development and reflect on how the ap-              for adults
plication of animals may be appropriate. Table 1 briefly          Suggestion 1. A therapist may use a therapy animal as a
                                                                   starting point to discuss decisions about having children
highlights the major tenets presented.
                                                                   or, for that matter, child-rearing practices.
   Clinicians should consider extending the boundaries
                                                                 Suggestion 2. Adults experiencing parenting challenges and
of where they perform their psychotherapy with their               couples who are experiencing marital dysfunction may
clients beyond the traditional office. Utilizing dogs as            find the metaphors and the stories related to bringing up
part of a therapeutic regime promotes taking walks.                children and learning to share one’s life with another
While walking, a therapist has an opportunity to deal              person as all appropriate topics. The presence of animals,
with issues in a more comfortable and less threatening             and examples incorporating animals, may give some
manner. Clinicians should become cognizant of their                clarity to the subject of generativity versus self-
own communities and plan out routes that may have                  absorption.
different purposes. For example, if privacy is strongly          Suggested developmental goals and treatment purposes
needed, the therapist should try to plan a walk that se-           for the elderly
cures the most privacy and the fewest disruptions.               Suggestion 1. Clients who have had a history of animals
Most routes should have a place where the clinician                within their lives may find the animal’s presence extremely
and client can stop and sit. This may be a point during            advantageous in reminiscing about past life events. A cli-
a session where more attention to details is needed.               nician may ascertain that the presence of the animal may
   Clinicians applying AAT in their practices may also             act as a catalyst for reliving past events.
                                                                 Suggestion 2. The clinician may also recommend to elderly
find the utilization of metaphors and stories incorpo-
                                                                   patients that they consider purchasing a pet. A client’s
rating animals as an appropriate extension. Clients in             sense of value could be tremendously enhanced as a con-
most cases should feel comfortable with these topics               sequence of feeling needed once again.
(since they are already being exposed to animals in the
52                                             Animal-Assisted Therapy

therapeutic environment). Stories portraying the chal-       an individual’s life, including functioning as a friend
lenges, obstacles, and successes that animals experi-        and a confidant. Animals comfort their companions
ence and overcome may be applied therapeutically to          and apparently serve as a buffer of protection against
help clients see the world or the struggles they face        adversity. Companion animals also appear to satisfy the
from a different perspective.                                numerous psychosocial needs of their human counter-
                                                             parts, including enhancing social stimulation, as well
                                                             as providing an outlet for leisure opportunities. Reports
           II. THEORETICAL BASES                             in the psychological literature suggest that unobtrusive
                                                             animals evoke social approaches and conversations
   Although not directly related to psychotherapy, the       from unfamiliar adults and children. Presence of an an-
following research will provide further insight into the     imal may become a social lubricant for spontaneous
value of the animal–human bond. Mental health pro-           discussions with passing strangers. The dog usually
fessionals may find this information useful in develop-       helps break the ice and makes it easier to initiate casual
ing a clearer perception of the impact of animals in the     discussion. In most cases, the topics initially begin
lives of people. Over the past 30 years there have been      around the animal’s presence.
several controlled studies documenting the correlation
of pet ownership and cardiovascular health. Erika
                                                                A. Companion Animals and Children
Friedman and her associates designed a study investi-
gating pet ownership with survival rates among pa-              Brenda Bryant reports that animal companions have
tients who were hospitalized for heart attacks,              been found to provide important social support for
myocardial infarctions, or severe chest pains. The re-       children. She also reports that animals within a home
sults illustrated a significant difference in life ex-       may assist children in developing a greater sense of em-
pectancy between the subjects who did have a pet             pathy for others, and may enhance a child’s self-esteem
versus those who did not. The results pointed out that       and social skills.
5.7% of the 53 pet owners compared with 28.2% of the            Bryant surveyed 213 children and identified four po-
39 patients who did not own pets died within one year        tential psychological benefits of animals for children.
of discharge from a coronary care unit. The findings          In 1990 she utilized the “My Pet Inventory” to assess
within this study have been replicated with similar          the subjects’ interests. A factor analysis of Furman’s in-
findings in a few other studies. This assumption was          ventory indicated that, from a child’s perspective, there
also noted by James Serpell, a leading authority on an-      are four factors in which the child–pet relationship can
imal–human relations, who detected that seniors who          be viewed as potentially beneficial. Bryant defined the
adopted pets appeared to experience a decreased fre-         factor of mutuality as having to do with the experience
quency of minor health problems. These minor health          of both giving and receiving care and support for the
problems included headaches, painful joints, hay             animal. The enduring affection factor identifies the
fever, difficulty paying attention, colds and the flu,         child’s perception of the lasting quality of his or her re-
dizziness, kidney and bladder problems, as well as a         lationship with the pet. This factor focuses on the per-
mirage of other mild illnesses. He suggested that the        manence of the emotional bond between the child and
associated physiological benefits could have been the         the animal. Enhanced affection, the third factor, identi-
result of increased physical activity.                       fies the child’s perception that the child–pet relation-
   On the other hand, there have been numerous stud-         ship makes him or her feel good as well as important.
ies investigating the psychosocial benefits of pet own-       Finally, the factor of exclusivity focuses on the child’s
ership. Conclusions from a vast majority of these            internal confidence in the pet as a confidant. This fac-
studies point out that pet ownership or interaction          tor appears to be extremely crucial for therapists to un-
with animals in therapeutic settings should be viewed        derscore. It is within this factor that a child may rely on
with the interaction of many other social influences.         the pet companion to share private feelings and secrets.
Those individuals who live highly stressed lives (fami-      This may be an important outlet, especially when there
lies in poverty or dislocation) may benefit more from         are limited friends and supports within the community
social supports, including support from animals.             or the home. There is evidence reported that a child
   Companion animals provide numerous benefits to             may also use an animal as a confidant. This appears to
the emotional well-being of humans. Animals at times         be an obvious alternative that some children may con-
take on numerous roles where there may be a void in          fide in their animals for social support. Many parents
                                                 Animal-Assisted Therapy                                               53
and clinicians over the years have remarked that they             Keith Cherry and David Smith suggest that persons
have observed children utilizing a family pet as a             with AIDS are especially susceptible to loneliness. Statis-
sounding board or as a safe haven to discuss their prob-       tics point out that a high portion of patients with AIDS
lems and troubles.                                             have diminished social support from friends, family, and
                                                               significant others. Therefore, it appears that the pets
         B. Therapeutic Benefits of                             owned by these individuals can act as important social
        Companion Animals for the                              supports. Programs such as Pets are Wonderful Support
                                                               (PAWS) have been developed to help persons with AIDS
       Chronically and Terminally Ill,
                                                               keep their pets as long as possible. The PAWS model rec-
         Persons with Disabilities,                            ognizes the importance of the companion animal in the
              and the Elderly                                  quality of life of his or her human counterpart. This
   Over the years, some reported studies have found            model appears to be applicable to any other special pop-
that pet ownership appears to decrease depression and          ulation living independently.
improve a healthier morale state. There have been stud-
ies indicating that war veterans found pet ownership to
be associated with improved morale. Furthermore,                           III. EMPIRICAL STUDIES
Lynette Hart and her associates have reported that serv-
ice animals appear to stimulate conversations and in-             Animal-assisted activities and AAT are most widely
teractions between the people who used the service             incorporated in institutional settings and large mental
animals and those who were just walking by. People             health organizations. Historically, these services have
with the assistance animals noted that their dogs cre-         been facilitated by mental health professionals in addi-
ated social opportunities with people. The dog appears         tion to nursing and other allied health specialists. In
to normalize the environment for the person with a dis-        most cases, these services have been applied in long-
ability and to act as a catalyst for a discussion.             term care facilities for the elderly, patients in hospitals,
   A benchmark study conducted by Roger Mugford on             children in a variety of therapeutic settings, and in-
the therapeutic value of pets for the elderly found that       mates in prisons.
older people (who live independently) who were given              Research reports the tremendous value in developing
a budgerigar had significantly improved social attitudes        an animal visiting program (or even having an animal
and appeared to be happier than those subjects who             living in residence) in facilities serving the elderly. In
were in the control group (after five months). Further-         most studies reviewed, the authors stressed that the resi-
more, animals living within the home of people with            dents in most nursing homes appeared eager for the
terminal illnesses or animals visiting those with similar      weekly AAT program. In some cases, residents kept track
constraints appear to lessen the individual’s fears, their     of the calendar in anticipation of interaction with the an-
sense of loneliness, and stress levels. Similar findings        imals. Several studies investigating the impact of AAA or
have been reported in studies evaluating the impact of         AAT on the elderly have concluded that the therapy (1)
an animal on the lives of people with terminal illnesses       appears to have a positive impact on enhancing attention
such as cancer and AIDS. A synthesis from these stud-          span; (2) is instrumental in positively enhancing ele-
ies suggests that these individuals seemed to feel more        ments of quality of life and well-being; and (3) appears
in control of their lives when they were able to take          to be effective in decreasing levels of depression among
care of an animal. Taking care of the animal and being         many residents as well as enhancing socialization and
able to hold and caress it seemed to cause them to focus       communication opportunities between the residents.
less on their illness.                                            Most research studies investigating AAA or AAT in
   Companion animals tend to help people use their             hospital settings have acknowledged similar outcomes
own strengths to help themselves and to be sensitive to        to those originally noted with the elderly. The conclu-
other people’s feelings and emotions, and therefore rec-       sions suggest that the animal-based programs appear to
ognize those occasions when they are needed or                 be a good distraction for the patients from their every-
wanted. Animals can act as human surrogates in a               day medical treatment in the hospital. The services also
number of roles, including friends and confidants. In           appeared to have a positive impact on health factors,
times when people are secluded in their homes, the             including decreasing pain and hyperactivity, helping
companionship of animals is extremely meaningful.              the patients feel calmer, as well as reducing high blood
They act as true friends.                                      pressure.
54                                                Animal-Assisted Therapy

   In a very revealing study, David Lee documented the          Clinicians are encouraged to utilize the standards of
incredible positive outcomes identified for an AAT pro-          practice guidelines suggested by the Delta Society.
gram initiated at the Lima State Hospital for the Crimi-        These standards highlight the need for reliability of the
nally Insane. Lee reported that the wards with animals          animal’s behavior, as well as the predictability that the
seemed to have a calming effect on the patients. There          animal’s behaviors will occur on a constant basis and
was also a noticeable reduction in the patients’ violent        that the animal can always be controlled or managed.
acts and suicide attempts. Similar outcomes were found             2. All animals incorporated in AAA or AAT must be
in the Washington State Correctional Center for                 permitted to rest and have breaks from their working
Woman program, which found that inmates who were                schedule. Attention must also be given to the suitability
involved in the training of service dogs appeared to be         of the animal to meet the specific goals prescribed by
less depressed and proud of their abilities in training         the practitioner for the specific session.
the animal.                                                        3. All clients should be interviewed to assess their
   An ultimate concern in most medical settings is the          comfort level with various animals, specific allergies,
health effects of the animals on the clients. This process      and, if relevant, past abusive behavior toward animals.
is now known as “zoonoses.” Philip Wishon reports                  4. The AAA or AAT must be integrated into the
that most cats and dogs carry human pathogens, which            client’s comprehensive treatment plan.
along with those carried by other animals have been as-            5. The practitioner should utilize the animal to aid
sociated with more than 150 zoonotic diseases. How-             in mastering developmental tasks and to promote re-
ever, Linda Hines and Maureen Fredrickson of the                sponsibility and feelings of self-worth as well as inde-
Delta Society point out that the data regarding the             pendence.
transmission of zoonotic diseases in any AAT program
have been minimal. Practitioners are advised to work
closely with veterinarians and other public health spe-
                                                                               B. Animal Welfare
cialists to ensure the safety of the animals as well as the        It is evident that the safety of one’s patient should
clients involved.                                               have the highest priority. Nevertheless, the therapist
                                                                should and must consider the safety and welfare of all
                                                                the animals used in therapeutic practice. To help iden-
            IV. SUGGESTIONS FOR                                 tify principles for animal safety and welfare, the author
           CLINICAL APPLICATION                                 has elected to incorporate some of the guidelines that
                                                                were identified in the Appendix of a chapter written on
                                                                ethical concerns by James Serpell, Raymond Cop-
           A. Training and Liability
                                                                pinger, and Aubrey Fine.
   Therapists considering incorporating animals                    The following briefly identify the concerns noted:
within their practice must seriously consider the fac-
tors of liability, training, as well as the safety and wel-        1. All animals must be kept free from abuse, discom-
fare of both the animal and the client. The Delta               fort, and distress.
Society’s Pet Partner Program strongly advocates that              2. Proper health care for the animal must be pro-
health care professionals have training in AAT and              vided at all times.
AAA techniques. Clinicians also need to be aware of                3. All animals should have a quiet place where they
best practice procedures ensuring quality and safety            can have time away from their work activities.
for all parties.                                                   4. Interactions with clients must be structured so as
   Gary Mallon and his associates, in a chapter in the          to maintain the animal’s capacity to serve as a useful
Handbook of Animal Assisted Therapy, provided guide-            therapeutic agent.
lines for developing and designing AAT programs.                   5. Situations of abuse or stress for a therapy animal
Within their chapter, the authors identified 20 princi-          should never be allowed.
ples that a practitioner should consider in developing             6. As an animal ages, his or her schedule for thera-
an AAA or AAT program. The following briefly high-               peutic involvement will have to be curtailed. Accom-
lights some of the major points:                                modations and plans must be considered. The
                                                                transition into retirement may be emotionally difficult
 1. All animals must be screened for their tempera-             for the animal as well. Attention must also be given to
ment to make sure they are appropriate candidates.              this dimension.
                                                     Animal-Assisted Therapy                                                      55

                    V. SUMMARY                                        tional settings. In S. A. Corson & E. O. Corson (Eds.),
                                                                      Ethology and nonverbal communication in mental health (pp.
   Animal-assisted therapy and AAA represent two dy-                  83–110). Oxford: Pergamon Press.
                                                                   Fine, A. H. (2000). Animals and therapists: Incorporating an-
namic approaches that may become valuable therapeu-
                                                                      imals in outpatient psychotherapy. In A. Fine (Ed.), Hand-
tic strategies in the treatment of children and adults (in            book on animal assisted therapy (pp. 179–211). San Diego:
individual and group therapy, in both outpatient and                  Academic Press.
institutional settings). Although there still exist limita-        Fredrickson, M., & Hines, L. (1998). Perspective on animal-
tions in investigating the efficacy of this treatment as               assisted activities and therapy. In B. C. Turner & C. C. Wil-
well as understanding best practice strategies, practi-               son (Eds.), Companion animals in human health (pp.
tioners should become more open-minded to the po-                     23–39). Thousand Oaks: Sage Publications.
tential contributions animals may make to the physical             Fredrickson, M., & Howie, A. (2000). Guidelines and stan-
and mental wellness of humans. Introduction of ani-                   dards for animal selection in animal-assisted activity and
mals into a therapeutic environment may provide a                     therapy programs. In A. Fine (Ed.), Handbook on animal
calming effect that contributes to the therapeutic out-               assisted therapy (pp. 100–114). San Diego: Academic Press.
                                                                   Friedman, E., Katcher, A. H., Lynch, J. J., & Thomas, S. A.
come. When animals are introduced with a well-
                                                                      (1980). Animal companions and one-year survival of pa-
thought-out plan, clinicians will not be disappointed                 tients after discharge from a coronary care unit. Public
with the outcome. Although not a panacea, the impact                  Health Reports, 95, 301–312.
of the human animal bond should not be underesti-                  Friedman, E., Katcher, A. H., Thomas, S., Lynch, J. J., & Mes-
mated as a positive therapeutic alternative.                                 .
                                                                      sant, P (1983). Social Interaction and blood pressure: In-
                                                                      fluence of animal companions. Journal of Nervous and
                                                                      Mental Disease, 171, 461–465.
       See Also the Following Articles                             Hart, L., Hart, B. & Begin, B. (1987). Socializing effects of serv-
                                                                      ice dogs for people with disabilities. Anthrozoos, 1, 41–44.
Alternatives to Psychotherapy I Bioethics I Parent–Child
                                                                   Lee, D. (1984). Companion animals in institutions. In
Interaction Therapy I Therapeutic Storytelling with
                                                                                 .
                                                                      Arkowo, P (Ed). Dynamic relationships in practice: Animals
Children and Adolescents
                                                                      in the helping professions (pp. 237–256). Alameda, CA:
                                                                      Latham Foundation.
                                                                   Levinson, B. M. (1962). The dog as a “co-therapist.” Ment.
                   Further Reading                                    Hyg., 46, 59–65.
Arkow, P. (1982). Pet therapy: A study of the use of companion     Mallon, G., Ross, S., & Ross, L. (2000). Designing and imple-
  animals in selected therapies. Humane Society of Pikes Peak         menting animal assisted therapy programs in health and
  Region, Colorado Springs, CO.                                       mental health organizations. In A. Fine (Ed.), Handbook on
Beck, A., Hunter, K., & Seraydarian, L. (1986). Use of ani-           animal assisted therapy (pp. 115–127). San Diego: Acade-
  mals in the rehabilitation of psychiatric inpatients. Psycho-       mic Press.
  logical Reports, 58, 63–66.                                      Mugford, R., & M’Cominsky, J. (1975). Some recent work on
Beck, A., & Katcher, A. H. (1983). Between pets and people:           the psychotherapeutic value of cage birds with old people.
  The importance of animal companionship. New York: G.P       .       In R. S. Anderson (Ed.), Pet animals and society (pp.
  Putnam’s Sons.                                                      54–65). London: Bailliere-Tindall.
Bryant, B. (1990). The richness of the child-pet relationship:     Serpell, J., Coppinger, R., & Fine, A. (2000). The welfare of
  A consideration of both benefits and costs of pets to chil-          assistance and therapy animals: An ethical comment. In A.
  dren. Anthrozoos, 3, 253–261.                                       Fine (Ed.), Handbook on animal assisted therapy (pp.
Cherry, K., & Smith, D. (1993). Sometimes I cry: The experi-          415–430). San Diego: Academic Press.
  ence of loneliness for men with AIDS. Health Communica-          Sklar, H. (1988). The impact of the therapeutic environment.
  tions 5, (3), 181–208.                                              Human Sciences Press, 18(2), 107–123.
Corson, S. A. & Corson, E. O. (1980). Pet animals as nonver-                   .
                                                                   Wishon, P M. (1989). Disease and injury from companion
  bal communication mediators in psychotherapy in institu-            animals. Early Child Development and Care, 46, 31–38.
                              Anxiety Disorders:
                             Brief Intensive Group
                          Cognitive Behavior Therapy
                                      Tian P. S. Oei and Genevieve Dingle
                                                     University of Queensland




    I.   Development and Description of Treatment                              I. DEVELOPMENT AND
   II.   Theoretical Bases                                                  DESCRIPTION OF TREATMENT
  III.   Empirical Studies
  IV.    Summary
         Further Reading
                                                                         Modern psychotherapy has its roots in Europe, and it
                                                                      was not until after the Second World War that the
                                                                      United States began to lead this field. During this period,
                                                                      psychotherapy flourished and grew at an enormous rate.
                            GLOSSARY                                  Behavior therapy, and later cognitive behavior therapy
                                                                      (CBT), led the earlier growth and in 1974 when Michael
brief intensive group cognitive behavior therapy (BIGCBT)             Mahoney published his first book in cognitive behavior
   A version of cognitive behavior therapy conducted in               therapy, the term CBT became entrenched.
   full-day sessions over a short time period (e.g., 3 consec-           Accumulated empirical evidence shows that CBT is
   utive days).                                                       efficacious for the treatment of many psychological and
                                                                      psychiatric disorders, ranging from anxiety, to eating dis-
                                                                      orders and the psychoses. For many patients, it can be
                                                                      argued that CBT is the treatment of choice for these dis-
                                                                      orders. At the turn of the new millenium, CBT was gen-
   Brief intensive group cognitive behavior therapy                   erally accepted as an evidence-based psychotherapy that
(BIGCBT) is a version of cognitive behavior therapy                   has benefited many people with mental health problems.
conducted in full-day sessions over a short time period,                 Although CBT can be delivered in individual or
for example, 3 consecutive days. This article presents                group settings, it is individual CBT that has received
the theoretical underpinnings and applications of                     the most research and thus provides the most clear-cut
BIGCBT, and a review of empirical studies showing the                 support for its efficacy. The application of CBT to group
effectiveness of a BIGCBT program for outpatients with                work has a much later history than individual CBT, and
panic disorder with or without agoraphobia.                           accordingly the evidence-based research is not nearly


Encyclopedia of Psychotherapy                                                                     Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                         57                                                   All rights reserved.
58                             Anxiety Disorders: Brief Intensive Group Cognitive Behavior Therapy

                                                          TABLE 1
                          A Sample of the Brief Intensive Group CBT Program for Panic Disorder
                                             with and without Agoraphobia

            Time                          Day 1                             Day 2                            Day 3

            08:00               Registration
            09:00               Introduction to anxiety            Group cognitive                    Drug therapy
                                  and phobias                        behavior therapy
            10:30               Morning break                      Morning break                      Morning break
            11:00               Anxiety and panic control          Breathing control control          Cognitive
            12:30               Lunch                              Lunch                              Lunch
            13:15               Planning                           Planning                           Planning
            13:45               Relaxation                         Relaxation                         Relaxation
            14:00               Exposure                           Exposure                           Exposure
            16:00–17:00         Group work/consultation            Feedback                           Positive thinking/
                                                                                                        self-help. Closing.

               Note: Adapted from Weir (2000). Health outcome of brief intensive group cognitive behavior therapy for anxiety
            disorders. Doctoral dissertation, University of Queensland, Brisbane, Australia.




as comprehensive. Since the success of individual and                      2. Problem versus sickness: We informed patients that
group CBT, researchers and clinicians have experi-                      to view their problems as a sickness did not promote
mented with the delivery format of CBT. The format                      their active role in the management of the problems, but
has ranged from brief to extended CBT. Brief CBT treat-                 could in fact hinder it.
ments comprise from one to four sessions, with a 1-hr                      3. Control versus cure: We emphasized that the main
session per week, while extended CBT treatments                         aim was for patients to take control of their anxiety and
range from 30 to 52 weekly 1-hr sessions. The average                   fear rather than to attempt to cure it forever. Being cured
length of time for individual CBT is about 10 weekly                    is a passive process that depends on someone doing
sessions, and the average length of group CBT is a                      something to you, whereas gaining control is an active
weekly 2-hr session for 12 sessions. More recent, we in-                process. We explained that control was a realistic and at-
troduced a BIGCBT intervention and demonstrated                         tainable goal. Gaining control of anxiety and fear would
that it has efficacy in the treatment of anxiety and                     enable patients to take charge and learn how to help
mood disorders.                                                         themselves. In addition to learning what techniques to
   The BIGCBT is delivered over 3 consecutive days,                     use and how to use them, patients also need to under-
with an attendance of 8 hrs per day. Psychiatrist Larry                 stand why they are using these techniques.
Evans and psychologist Bevan Wiltshire initially started
the BIGCBT in the early 1980s for the treatment of pa-                     BIGCBT was delivered in a group format with the
tients with anxiety disorders, in particular panic disorder             aim of making the program more cost effective. Refer-
with agoraphobia. In 1984, a group of psychologists,                    rals were made by the patients’ medical officers. Group
Tian Oei, Justin Kenardy, and Derek Weir, joined the                    sizes averaged 8 participants. The group format pro-
group and further developed and evaluated the treat-                    vided a structured setting in which to learn the skills
ment package.                                                           delivered by the program. It also provided social sup-
   The BIGCBT was developed with the following prin-                    port, and a more socially relevant context for behav-
ciples in mind:                                                         ioral and attitudinal change and reinforcement than
                                                                        would an individual CBT context.
   1. Self-help: We wanted patients to take an active                      A team of experienced clinicians delivered BIGCBT,
role in the management of their disorders. We strongly                  including psychiatrists, psychologists, and nurses. It was
encouraged them to do so by providing a rationale, ac-                  ensured that all clinicians had a good grounding of CBT
tively teaching them self-help skills and encouraging                   and had observed the whole BIGCBT program before
them to experiment with solutions to their problems.                    taking responsibility for the delivery of group sessions.
                             Anxiety Disorders: Brief Intensive Group Cognitive Behavior Therapy                        59
No one clinician delivered the entire BIGCBT program.            strating that at one year follow-up, 85% of the patients
Clinicians were allocated to a session or sessions of the        treated with BIGCBT were either symptom free or had
BIGCBT program based on interest, knowledge, and                 significant symptom reduction. The finding that per-
time availability.                                               sonality variables were not changed by the BIGCBT
   An example of the 3-day program with the contents of          treatment was supported by a study by Clair, Oei, and
each session is presented in Table 1. There were three           Evans in 1992, using the same measures with the addi-
blocks of exposure sessions, taken by at least two clini-        tion of the Fundamental Interpersonal Relations Orien-
cians. When group membership was greater than eight,             tation-Behavior Scale (FIRO-B). This 1992 study
three or more clinicians were used. Fellow clinicians            showed that personality variables derived from the pre-
were encouraged to “sit in on” other sessions in order to        viously mentioned three instruments were no different
provide feedback and peer support to the therapist. The          between patients who responded and did not respond
participation of Dr. Evans in every program provided sta-        to the BIGCBT treatment. Similar to previous findings,
bility, consistency, and quality assurance for the program.      personality characteristics did not predict treatment
                                                                 outcome.
                                                                    A study by Weir in 2000, supervised by Evans and
           II. THEORETICAL BASES                                 Oei, compared 71 waiting-list control patients with 206
                                                                 patients with anxiety disorders, on clinical and func-
   The theoretical basis of the BIGCBT was derived               tional outcome measures. Clinical outcome measures
from the cognitive behavioral framework and encom-               used were self-report scales such as FQ, MPI, FSS, the
passed the elements of clinical assessment and diagno-           State Trait Anxiety Inventory (STAI) and the HDHQ.
sis, psychoeducation of cognitive and behavioral skill           Clinician-rated measures such as Hamilton Anxiety Rat-
components, exposure, relaxation training, and home-             ing Scale (HAM-A) and Hamilton Depression Rating
work assignments. The Quality Assurance Project of               Scale (HAM-D) were also used. The functional outcome
the Royal Australian and New Zealand College of Psy-             measures were the Medical Outcome Study Short Form
chiatrists treatment guidelines also contributed to the          Health Survey (SF 36), the Quality of Life Inventory
design of the BIGCBT.                                            (QOLI) and the Health Schedule Utilization (HSU). Pre-
                                                                 to posttreatment comparison between the BIGCBT and
                                                                 control groups showed that the BIGCBT group made sig-
           III. EMPIRICAL STUDIES                                nificant improvements when compared to the control
                                                                 group, on all the clinical outcome measures. The re-
   BIGCBT was run at a community outpatient clinic.              ported effect sizes for the BIGCBT group ranged from
Therefore, evaluation of the intervention used an effec-         large (HAM-A = 1.24; HAM-D = .99) to small (STAI =
tiveness approach rather than an efficacy approach. Oei           .22). There was a small but significant effect size for the
and colleagues’ previous publications address a diversity        change in MPI and HDHQ scores. This personality
of topics, including the development of new instruments          change was not consistent with the earlier studies.
to measure catastrophic cognitions; the validation of               An important part of Weir’s study is that it reported on
outcome measures such as the fear questionnaire (FQ);            6-year follow-up results. The results showed that the
psychopathology of panic attacks and panic disorders;            treatment gains made by BIGCBT patients were main-
and treatment effectiveness. In 1991, Evans, Craig Holt,         tained over the long term. The findings also showed that
and Oei reported the first long-term follow-up data               most of the gains were made at posttreatment, and that
using the BIGCBT. They found that at posttreatment,              the length of time of follow-up (ranging from 1 to 6
BIGCBT was significantly better than the no treatment             years) did not improve the posttreatment gains.
waiting-list control on the outcome measures of the FQ              The most interesting finding from the Weir study
and the fear survey schedule (FSS). However, there was           was in regard to the functional outcome measures. The
no difference in the scores for the Maudsley personality         results from the SF-36 showed that up to 6 years after
inventory (MPI) and the hostility and direction of hos-          the BIGCBT treatment, the SF-36 profiles of the treated
tility questionnaire (HDHQ), suggesting that neither of          group were almost the same as those of the general
these personality variables was affected by the BIGCBT           population, and much better than the SF-36 profiles of
treatment. One-year follow-up results showed that treat-         people with anxiety disorder problems in the national
ment gains were maintained. Clinical interview data              survey. This implies that long after treatment, the pa-
confirmed the FQ and FSS self-report data by demon-               tients with anxiety disorder who were treated with the
60                          Anxiety Disorders: Brief Intensive Group Cognitive Behavior Therapy

BIGCBT can expect to have almost the same general                       See Also the Following Articles
health perception as the general population. This find-
                                                                Cognitive Behavior Therapy I Cognitive Behavior Group
ing was complemented by the results of the QOLI that
                                                                Therapy I Panic Disorder and Agoraphobia
indicated that patients treated with BIGCBT were rela-
tively free of psychological distress and had a more re-
alistic expectation of their living conditions.                                    Further Reading
   The long-term effectiveness of BIGCBT was also re-           Bialkowska, G. (2000). The efficacy of a brief intensive group
ported in a 1997 study conducted by Oei and Evans with             cognitive behavior therapy for panic disorder and comorbid
Michael Llamas. This study investigated the possible im-           alcohol dependent patients, Master’s thesis, University of
pact of concurrent medication use on the long-term out-            Queensland, Brisbane, Australia.
come of BIGCBT for panic disorder with or without                                   .
                                                                Clair, A., Oei, T. P S., & Evans, L. (1992). Personality and
agoraphobia. The researchers found that preexisting                treatment response in agoraphobia with panic attacks.
medication (antianxiety, antidepressant, or a combina-             Comprehensive Psychiatry, 33, 310–318.
tion of these) did not significantly enhance or detract                                           .
                                                                Evans, L., Holt, C., & Oei, T. P S. (1991). Long term follow
from the long-term outcome of the BIGCBT program.                  up of agoraphobics treated by brief intensive group cogni-
                                                                   tive behavior therapy. Aust New Zealand Journal Psychiatry,
   The BIGCBT has also been applied to the treatment of
                                                                   25, 343–349.
patients with comorbid alcohol use disorder and panic
                                                                                                   .
                                                                Kenardy, J., Evans, L., & Oei, T. P S. (1992). The latent struc-
disorder with or without agoraphobia. The 2000 report              ture of anxiety symptoms in anxiety disorders. American
by Bialkowska, supervised by Oei and Evans, docu-                  Journal of Psychiatry, 149, 1058–1061.
mented that concurrent addition of the BIGCBT for                                      .
                                                                Khawaja, N., Oei, T. P S., & Baglioni, A. (1994). Modification
panic disorder to the standard hospital treatment for al-          of the Catastrophic Cognitions Questionnaire (CCQ-M)
cohol abuse produced better clinical outcomes than the             for normals and patients: Exploratory and LISREL analy-
standard hospital treatment and a placebo treatment. It            ses. Journal of Psychopathology and Behavioral Assessment,
was found that BIGCBT had an impact on self-reported               16, 325–342.
anxiety but not on alcohol outcome measures.                    Mahoney, M. J. (1974). Cognition and behavior modification.
                                                                   Cambridge, MA: Ballinger.
                                                                         .
                                                                Oei, T. P S. (1999). A group Cognitive Behavior Therapy pro-
                                                                   gram for anxiety, fear and phobias: A Therapists Manual,
                  IV. SUMMARY                                      CBT Unit, Brisbane.
                                                                           .
                                                                Oei, T. P S., Llamas, M., & Develly, G., (1999). Cognitive
   There is enough evidence to suggest that the                    changes and the efficacy of CBT with panic disorders with
BIGCBT is an effective treatment for anxiety disorders,            agoraphobia. Behavioral and Cognitive Psychotherapy, 27,
in particular for panic disorder with and without agora-           63–88.
phobia. The exact mechanism for the effectiveness of            Oei, T. P. S., Llamas, M., & Evans, L. (1997). Does concur-
this treatment is still unknown. Furthermore, the effec-           rent drug intake affect the long-term outcome of group
tiveness of the BIGCBT is demonstrated by a single                 cognitive behavior therapy in panic disorder with or
                                                                   without agoraphobia? Behaviour Research and Therapy,
group of researchers in one place and needs to be repli-
                                                                   35, 851–857.
cated by different researchers and in different locations                 .
                                                                Oei, T. P S., Moylan, A., & Evans, L. (1991). Clinical utility
before anything more substantial can be said about the             and validity of the Fear Questionnaire. Psychological As-
general clinical utility of the BIGCBT. What can be said           sessment, 3, 391–397.
with some degree of confidence, however, is that our             Weir, D. (2000). Health outcome of brief intensive group cogni-
findings add to the robustness of the delivery of CBT in            tive behavior therapy for anxiety disorders. Doctoral disser-
the treatment of psychological disorders.                          tation, University of Queensland, Brisbane, Australia.
                     Anxiety Management Training
                                 Richard M. Suinn and Jerry L. Deffenbacher
                                                      Colorado State University




    I.   Description of Treatment                                            I. DESCRIPTION OF TREATMENT
   II.   Case Illustration
  III.   Theoretical Basis                                                 Anxiety management training (AMT) typically takes
  IV.    Applications and Exclusions
                                                                        six to eight sessions after an assessment suggests that a
   V.    Empirical Studies
  VI.    Summary
                                                                        self-managed relaxation approach is appropriate. It
         Further Reading                                                may take a few sessions longer if other emotions (e.g.,
                                                                        anger) or psychophysiological disorders (e.g., tension
                                                                        or migraine headaches) are added to anxiety treatment
                            GLOSSARY                                    goals. AMT can be conducted with individuals or in
                                                                        small groups.
AMT Acronym for anxiety management training.                               The core characteristics of AMT include guided im-
anxiety management training A self-control intervention                 agery, anxiety arousal, application of relaxation for self-
   using relaxation as a coping skill to prevent or reduce anx-         managed anxiety reduction, and transfer of relaxation
   iety arousal.                                                        coping skills to the external environment. Guided im-
anxiety scene A concrete event from the client’s actual expe-
                                                                        agery involves the introduction of relaxation imagery
   rience associated with anxiety being aroused.
biofeedback Methods for relaxation training that employ
                                                                        to strengthen the relaxation response, and it also in-
   equipment to monitor and provide feedback on physiolog-              cludes anxiety imagery to precipitate anxiety arousal.
   ical responses, such as changes in muscle tension or finger           Anxiety is precipitated during sessions in order to pro-
   temperature.                                                         vide clients with the opportunity to become more
early warning signs Internal cues such as tension in shoul-             aware of their anxiety arousal and to identify the early
   ders, upset stomach, or specific thoughts that indicate the           warning cues and employ relaxation that will reduce
   onset or early stages of anxiety arousal. AMT trains clients         the actual experiences of anxiety. Thus, clients first
   to attend to these cues and initiate relaxation coping skills        practice controlling anxiety in the safe setting of ther-
   to abort anxiety or stress arousal.                                  apy prior to real-life applications for anxiety reduction.
progressive or deep muscle relaxation A method of relaxation            As clients gain in self-control of anxiety over the course
   training that has clients systematically tense and release
                                                                        of AMT, the anxiety-arousing capacity of anxiety scenes
   the muscles of the body.
relaxation scene A concrete event from the client’s actual ex-
                                                                        is increased and the degree of therapist assistance in re-
   perience that is associated with being relaxed.                      laxation retrieval is decreased. Homework assignments
relaxation training The process of developing a basic relax-            to apply relaxation in specific situations and at any
   ation response, usually done through biofeedback or deep             time anxiety is experienced are used to ensure the
   muscle relaxation.                                                   transfer of skills to in vivo application.


Encyclopedia of Psychotherapy                                                                       Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                           61                                                   All rights reserved.
62                                             Anxiety Management Training

   AMT is easily adapted to other distressing emotions         exposure—that is, after the client signals anxiety—the
and to physiological conditions associated with stress.        anxiety scene is terminated, and the therapist reintro-
For example, in applying AMT to anger, the training pro-       duces relaxation, first by visualization of the relaxation
cedures remain the same, but the content of the scenes         scene and then by a review of the muscles without ten-
and homework focus on these emotions rather than on            sion. As time allows, this process is repeated, with the
anxiety. In adapting AMT to tension headaches, stress-in-      anxiety exposure interval lengthened to 20 to 30 sec-
ducing scenes may be broader than anxiety, for other           onds. Homework involves continued self-monitoring
emotions may trigger tension headaches. Clients can also       of anxiety, daily practice of relaxation without tension,
identify the early warning signs of headaches and apply        and application of relaxation in nonstressful situations.
relaxation skills when these cues are perceived.
                                                                                   C. Session 3
                    A. Session 1                                  This session follows the steps outlined in Session 2,
   Session 1 is devoted primarily to deep muscle relax-        with two major additions. Self-initiated relaxation and at-
ation, whereby muscles are first tensed and then re-            tention to the anxiety-arousal symptoms are prompted,
laxed. An emphasis on awareness of tension is added            so that clients can identify personal signs associated with
by instructing clients to pay attention to feelings of         anxiety. These might involve symptoms such as clenched
muscle tension and to notice the contrast between the          fists, heightened respiration, feelings of panic, thoughts
tensed and relaxed sensations. For most clients identi-        of self-doubt, images of great inadequacy, and the like. By
fying a relaxation scene is useful for furthering control      training clients in becoming aware of the signs of anxiety
of relaxation. Such a scene should be a real-life event        and using their presence to initiate relaxation, AMT
involving a specific relaxing moment from the client’s          teaches clients not only how to reduce anxiety when it is
life. The client and therapist develop this scene prior to     experienced, but also to identify the early anxiety cues in
initiating progressive relaxation. After deep muscle re-       order to prevent further anxiety buildup.
laxation, the client is instructed to visualize the relax-        By this session the client should be able to achieve a
ation scene and to permit that experience to further           relaxated state in a brief time, typically in one to three
increase the relaxation level. Progressive relaxation and      minutes. After the client has relaxed, the therapist initi-
relaxation scene visualization typically take about 30         ates anxiety arousal by having the client visualize the
minutes. Homework involves daily practice of progres-          60-level scene. When the client signals anxiety, the
sive relaxation, self-monitoring and recording anxiety         therapist introduces the new instructions for attending
arousal, and the identification of one or two moderate          to anxiety symptoms: “Pay attention to how you expe-
anxiety scenes to be used in the next session.                 rience anxiety; perhaps it is in your body signs such as
                                                               tension in your neck muscles, tightness across your
                                                               stomach, or your heart rate or maybe in some of your
                    B. Session 2                               thoughts.” After about 30 seconds of anxiety arousal,
   This session involves the development of an anxiety         relaxation is retrieved, with the therapist guiding the
scene, inducing relaxation, and one or more trials of          client through muscle reviews, relaxation imagery, or
anxiety arousal followed by relaxation retrieval. The          deep breathing-based relaxation. This process is re-
anxiety scene should be a real experience that elicits a       peated, usually three to five times, until the end of the
moderately high level of anxiety (about 60 on a scale          session. Homework involves identifying a 90-level
where 100 is extreme anxiety). Following determina-            scene for the next session and using relaxation coping
tion of an anxiety scene, relaxation is introduced. Typi-      skills to control anxiety wherever it is experienced. Ef-
cally, clients will be able to become relaxed not by           forts are recorded in the self-monitoring log.
tensing muscles, by simply focusing on and relaxing
each muscle group. When the client is relaxed, anxiety
                                                                                   D. Session 4
arousal is initiated through the therapist’s instructions
to switch on the anxiety scene, to use the scene to re-           In this session, a 90-level scene is developed. Use of
experience anxiety, and to signal the onset of this anxi-      the 90-level scene provides the client with the oppor-
ety. The therapist includes both scene-setting and             tunity to cope with high levels of anxiety arousal. In
anxiety-arousal details from the scene and uses appro-         addition, the client starts to assume more responsibility
priate voice emphasis (e.g., volume and tone) to aid in        for controlling anxiety. Instead of the therapist termi-
anxiety arousal. After about 10 to 15 seconds of anxiety       nating the anxiety scene and reinitiating relaxation, the
                                                Anxiety Management Training                                          63
client initiates relaxation by using the relaxation scene,      mother of two teenagers, worked as a project manager
a muscle review, deep breathing-cued relaxation, or             for a computer company. She was diagnosed with gener-
whatever method personally works best. The 60- and              alized anxiety disorder (GAD). She also sought help re-
90-level scenes are alternated to provide practice in           garding tension headaches and problems involving
anxiety management. Homework involves the self-                 experiencing anger while driving. During intake, she re-
monitoring of early warning signs of anxiety and the            ported being anxious and tense most of the time. Anx-
immediate application of relaxation to abort arousal            ious feelings were marked by a general sense of unease
any time anxiety is experienced. Clients are alerted to         and foreboding and by heightened general physiological
do this any time they encounter situations known to be          arousal and agitation, a feeling of being jumpy and on
anxiety arousing. Clients are also encouraged to rou-           edge, marked tension in the neck, shoulders, forehead,
tinely monitor anxiety signs four times a day (i.e., once       and hands, and a knot in her stomach, sometimes ac-
in the morning, midday, afternoon, and evening). All            companied by nausea and stomach upset. She reported
efforts to monitor anxiety signs and apply relaxation           that the anxiety seemed to accumulate during the day,
are recorded in the client’s self-monitoring log.               becoming worse in the afternoon and evening. She also
                                                                reported moderately severe tension headaches on a
                                                                nearly daily basis, headaches that were related to her
                     E. Session 5
                                                                chronic anxiety. In the past, her physician had pre-
   In Session 5, the 60-level scene is often dropped and        scribed benzodiazapines for this anxiety, and she cur-
replaced with a higher level anxiety scene. This session        rently took Valium approximately three times a week.
also completes the fading out of therapist control and          She reported frequent periods of “stewing” (unrealistic
the completion of client self-control. Following client         worry) needlessly about several topics: (1) work per-
self-initiated relaxation, the therapist switches on the        formance (e.g., that she would fail and be fired, even
anxiety scene, but all activities from that point on are        though she had good to excellent performance reviews
client-controlled. While in the anxiety scene the client        for several years; or that projects would not be com-
initiates relaxation to deactivate arousal and decides          pleted or would be totally inadequate, even though this
when to terminate the scene. After signaling the thera-         had not happened in the past); (2) the health and safety
pist that this has occurred, the therapist readies the          of her husband and children (e.g., continued preoccupa-
client for another scene and the process is repeated.           tion with a mole on her husband’s neck, even though it
Homework is the same as suggested in Session 4.                 had been checked by his family physician and a derma-
                                                                tologist; and frequent images that her husband or chil-
                                                                dren had been killed or hurt in a car accident); and (3)
                  F. Sessions 6–8
                                                                finances (e.g., being worried that they would not be able
   With the exception of the introduction of new high           to send their children to college, even though she and
level anxiety scenes, the same format used in Session 5         her husband had good, secure jobs). She indicated that
is used in Sessions 6–8. Moreover, application to other         the worry and anxiety led to such great weariness and fa-
sources of distress is also encouraged. Length of time          tigue that she often went to bed early or watched televi-
between sessions may be increased in order to provide           sion to escape the anxiety, worry, and headaches. She
more opportunities for application and to facilitate            also experienced frequent intense episodes of anger in
transfer and maintenance. Plans for maintenance and             her 40-minute commute to and from work. She indi-
relapse prevention are discussed during these sessions          cated that this anger carried over into and influenced her
as well. When self-control of anxiety is established,           work negatively and was another source of stress that
usually by Session 8 termination is initiated, or AMT is        contributed to her fatigue and headaches.
integrated with other interventions. Booster sessions              She was seen for two sessions for assessment involv-
may sometimes be employed prior to clients con-                 ing interviewing, self-monitoring anxiety and tension
fronting future events to facilitate relapse prevention.        headaches, and completion of psychometric instru-
                                                                ments. AMT sessions are described next and are num-
                                                                bered to follow the outline presented earlier.
            II. CASE ILLUSTRATION                                  Initial portions of AMT Session 1 involved the thera-
                                                                pist presenting the rationale for using AMT in the fol-
   Patient Characteristics. This case illustrates the basic     lowing way:
AMT approach, with some modifications for the charac-               Rationale: Jane, it seems like the primary issues are
teristics of the specific client. Jane, a 37-year-old married    the cycles of worrying and anxiety where you get tense
64                                              Anxiety Management Training

all over, especially in the neck, shoulders, and stomach.       do our jobs, I think that we can develop these skills to
This only gets worse when you’re angry and stressed             relax whenever you are worried and tense in about 7 to
when driving. All this seems to trigger the headaches           10 sessions. How does this sound to you?
and makes you worn out in the evening so that you just             The remainder of the session was spent developing a
duck out by going to bed early or watching a lot of TV.         relaxation scene (see as follows), initiating progressive
You also indicated that you do much better when you             relaxation training, and presenting the relaxation scene
relax, but most of that is by watching TV or sleeping off       twice. Homework included self-monitoring worry and
the stress, and you want to have better ways to relax           anxiety and daily relaxation practice.
and cope. Is that how it seems to you? (She responds               Relaxation Scene: It is last August when you were
affirmatively.) I think there are some ways we can do            lying on that big rock out in the middle of the river
that and would like to describe them and see what you           near your favorite camping spot. It was about 3:30 in
think. The first step is to help you learn how to really         the afternoon, and you are there alone and can only
relax. If we agree, I will show you how to do this later        hear the sound of the road off in the distant (general
in today’s session. In the beginning, it will take you 20       scene setting details). You are lying there on your back,
to 30 minutes, but with practice you’ll be able to do it        looking up at the sky, the brilliant blue cloudless sky.
much faster. Once you can relax yourself well, we’ll de-        The canyon is pretty steep on both sides, so the sky is
velop several quick ways for you to relax whenever,             framed in the gray of the rocks and green of the pine
wherever you start feeling anxious. The second step is          trees as you look up (more specific visual detail). You
to help you become more aware of when tension is                can hear the breeze rustling through the pines and hear
coming on so that you can pay attention to those                the river gently gurgling as it flows over the rocks
thoughts and feelings and initiate the relaxation skills.       below you (auditory detail). The air is warm, but not
We’ve already started some of this when we had you              hot and has that wonderful “early fall smell” you love
keep track of your feelings in your diary (referring to         so much (temperature and olfactory detail). You are
self-monitoring log). The third step will really give you       warm, but not hot, feeling like the sun has soaked
lots of practice in identifying the feelings of anxiety and     through you, that wonderful feeling like you have
relaxing away the tension so that you can have that             melted right into the rock (temperature, emotional,
“calm, clear-headed feeling” you like. We’ll do this in         and kinesthetic detail). You are very peaceful, totally
the following ways. In the sessions, I will have you vi-        relaxed, and worry free, thinking that there is no place
sualize situations that have made you anxious in the            you would rather be. Feeling calm and clear headed.
past, like a week ago when you were anxious about               The colors and life seem clear and vibrant. Warm, re-
presenting your report at the project manager’s meet-           laxed, without worry, molded into that big rock in the
ing. Then, we will initiate relaxation and help you calm        river (cognitive and affective detail).
down and be relaxed again. We will do this over and                Session 2 involved a review of homework, the devel-
over so that you get really good at recognizing anxiety         opment of a moderate anxiety scene (i.e., approxi-
and calming down by relaxing. Initially, we will start          mately 60 on a 100-point scale), further relaxation
with moderate anxiety, but as you get better at relaxing        training, anxiety arousal/relaxation coping, and assign-
away the tension, we’ll increase the anxiety level, and         ment of homework. Relaxation training included prac-
have you take more and more control over the relax-             tice with three new relaxation coping skills introduced
ation. You’ll also practice the relaxation to cope with         for this client: (1) relaxation without tension (review of
the worry and anxiety in real life. You’ll write about          the muscles without tensing them); (2) breathing cued
those experiences in your diary, and we’ll go over them         relaxation (taking three to five slow, deep breaths, re-
each session. We’ll also want to help you use the relax-        laxing more on each breath out); and (3) cue-con-
ation to abort those nasty headaches you get, and               trolled relaxation (pairing slow repetitions of the
maybe on the anger you get when driving. Being able to          phrase “calm control” with relaxation). Focus was then
relax should also help with that stewing or worrying            directed to identifying an anxiety scene. The anxiety
you do. You indicated that when you are calm, you               scene at the 70-level was as follows:
think things through pretty well, but not when you are             Anxiety Scene: It was Friday evening, three weeks
uptight. The procedures I was describing should help            ago. You were home alone as Jim (husband) and the
you calm down and think things through calmly be-               kids had gone to the movies (scene-setting detail). It
cause you will be able to relax and calm yourself. This         had been a tough day at work, and once again, you
will take a lot of work on both our parts, but if we both       were frazzled and tired and avoided more stress by stay-
                                               Anxiety Management Training                                             65
ing home (general emotional detail), sitting on the               This process was repeated five times. Two relaxation
couch trying to zone out and watch TV, but couldn’t            coping skills were employed with each repetition.
stop thinking about work. You know it’s stupid because         Homework involved self-monitoring, daily practice of
you were well ahead of schedule, but kept thinking             progressive relaxation, and practice of relaxation cop-
about how far behind you were and how much you had             ing skills at least once per day in nonstressful condi-
to do. You kept worrying that it was all going to fail and     tions (e.g., waiting for a friend for lunch).
be your fault, how they were going to find out how in-             Sessions 3 and 4 followed the format of Session 2,
competent you are. Also, you were worrying about Jim           except that the client relaxed herself by “whatever
and the kids. He said they might get a bite to eat and         method works best for you” prior to rehearsal of relax-
catch the late movie, but you were worrying that they          ation in response to anxiety scenes. An additional 60-
had been in an accident. You were a mess and couldn’t          level scene was added, and scenes were alternated
stop thinking about all of this stuff (cognitive detail).      during the session. During anxiety scene arousal, Jane
You had that anxious-all-over feeling, like you couldn’t       was asked to pay attention to the signs associated with
sit still, all wound up, but no place to go. That sense of     her experience of anxiety; these turned out to be ten-
doom and bad things happening just sort of hung on             sion in the neck and shoulders and clenching of the
you. Your shoulders were hard as rocks, stomach was            hands. Homework involved continued daily practice of
churning away, and your head just kept turning over all        relaxation without tension, application of relaxation
the problems at work. You had another of those terrible        coping skills whenever anxious, but with the caveat not
headaches. That dull constant ache in the back was re-         to expect success every time, and continued self-moni-
ally wearing on you (emotional and physiological de-           toring of anxiety with the addition of recording appli-
tail).                                                         cations of relaxation coping skills. The client was also
   After the details of the anxiety scene were confirmed,       instructed to identify two anxiety/worry scenes at ap-
relaxation was initiated through therapist-directed re-        proximately the 70-level.
laxation without tension. After the client signaled being         By the beginning of Session 5, the client was show-
relaxed, the anxiety scene was introduced, and relax-          ing some successful in vivo applications, having been
ation was practiced (see sample instructions below).           able to partially reduce tension and anxiety on several
   Anxiety Scene Introduction: In a moment, we are going       occasions (i.e., she was able to lower her anxiety levels
to have you practice reducing your anxiety. I will ask         by 30 to 40 units, although she could not yet com-
you to imagine the anxiety scene involving being home          pletely eliminate anxiety). Session 5 included two
alone worrying about work and the kids. When I do, I           changes. First, two 70-level scenes were developed and
want you to put yourself into that scene. Really be there      alternated. Second, increased client self-control was
and experience that worry and anxiety. As we discussed         fostered by having the therapist terminate the anxiety
earlier, signal me when you are feeling anxious by rais-       scene after a period of anxiety arousal, but having the
ing your index finger. After a few seconds of being anx-        client relax away the tension and signal the therapist
ious, I will ask you to erase that scene and will help you     when relaxation was achieved. For homework, in order
retrieve that relaxed clear-headed feeling. When you           to decrease the building stress and anxiety that ap-
are relaxed signal me again. So right now, put your self       peared to trigger tension headaches, the client agreed
into this scene … (therapist describes the anxiety scene       to scan herself for cues of tension and to self-initiate a
using voice inflection to increase attention to and the         three-minute period of relaxation at the following
experience of anxiety) … After 20 seconds, the client          times—in her car before she entered work, midmorn-
signals … Ok, I see your signal. Now continue to pay           ing, after lunch, midafternoon, in her car before start-
attention to that anxiety. Let it build and pay attention      ing home, and at least once during the evening. She
to how you’re feeling it … maybe in the neck and               was also asked to apply relaxation coping skills any
shoulders … maybe across the stomach area … let it             time she experienced any negative emotional arousal.
build and notice it … really worry and be anxious                 Sessions 6–9 followed a similar format. However, the
about work … (after 25 seconds) … Ok, now erase that           anxiety level of the scenes increased to a 90-level as this
scene from your mind and once again switch back on             was as anxious as the client felt when worried and anx-
your relaxation scene. You’re there on the rock, relaxed       ious. Two driving anger scenes (see the following ex-
and warm. Signal me when you are relaxed again …               ample) were also added to Sessions 7–9 to address her
(When the client signaled, this was followed by relax-         anger when driving. Instructions during rehearsal
ation without tension.)                                        shifted to full client self-control. The therapist initiated
66                                            Anxiety Management Training

the visualization of the anxiety scene. The client sig-       support gains and troubleshoot issues. Termination
naled the experience of anxiety by raising her finger          was achieved at four-month followup, although the
but kept her finger up. She then continued to visualize        client was seen for two additional booster sessions
the scene and initiated relaxation coping skills, signal-     when her daughter became ill, and the client began
ing by lowering her finger when she was relaxed. At            worrying about potential health complications.
that point, the therapist cleared the anxiety scene and
instructed her to pay attention to her sense of control
over the anxiety and her self-efficacy at anxiety man-                       III. THEORETICAL BASIS
agement. Finally, to provide greater opportunities for in
vivo practice and to initiate a transition to maintenance        AMT was developed in 1971 as a solution to the in-
and relapse prevention, the time interval between Ses-        appropriateness of desensitization for dealing with
sions 7, 8, and 9 was lengthened to two weeks.                what is now called generalized anxiety disorder (GAD).
   Anger Scene: It was about two weeks ago. You were in       Desensitization is effective for phobias but requires the
the left lane on the two lane freeway ramp. You were          identification of the stimuli precipitating the anxiety
following a woman driver in a blue Dodge with Ne-             response. In GAD, clients experience a more chronic,
braska plates. As the light change, the woman in front        generalized state of anxiety, and the external cues elicit-
of you accelerated and swerved into the right lane in         ing anxiety cannot be identified so precisely. Desensiti-
front of a large dump truck. The truck nearly hit her         zation was, therefore, not applicable, and alternative
and blasted her with his horn. She then swerved back          interventions were needed.
into your lane, nearly hitting you (setting detail). In-         AMT is based on Richard Suinn’s suggestion that
stantly, you were angry, really pissed. Your hands were       clients can be taught to identify the internal signs, both
clenched around the wheel, shoulders knotted, stom-           cognitive and physical, that signal the presence of anxi-
ach churning, and you had that hot flush come across           ety and to react to those signs by engaging in responses
your chest and into your neck and face (emotional and         that remove them. This formulation was based on learn-
physiological detail). You were thinking, “Crazy bitch!       ing theory that conceptualized anxiety as a drive state
She’s going to get us all killed! Where the hell did she      and postulated that behaviors could be learned to elimi-
learn to drive, at some kind of destruction derby? I          nate the drive. Anxiety was viewed as having both re-
ought to run her off the road and save us all a lot of        sponse and stimulus properties. It was a response to
trouble (cognitive detail).”                                  prior internal and/or external anxiety-arousing stimuli.
                                                              Its stimulus properties involve the potential to elicit
   Termination. The client had been demonstrating good        new responses such as avoidance and escape. As such, it
anxiety management. She reduced significantly the fre-         was argued that anxiety’s stimulus properties could be-
quency and intensity of worry/anxiety periods per day,        come associated with new responses, such as coping re-
reduced headache frequency from almost daily occur-           sponses. AMT, therefore, does not require clients to
rences to approximately one per week with an intensity        identify the stimuli that precipitate their anxieties. In-
of a 3 on a 10-point scale, down from an intensity of 7       stead, the experience of anxiety itself is used to train the
prior to therapy, and reported lessened anger while driv-     client in coping. The goal is to provide the client with a
ing. A staggered termination was undertaken in order to       relaxation coping skill with which to deactivate anxiety
facilitate maintenance and relapse prevention. Booster        once it occurs and to train the client in recognizing and
sessions were scheduled at one- and four-month post-          using arousal as the cue to initiate that coping skill. In
therapy intervals, and continued self-monitoring and          theoretical terms, AMT trains clients in responding to
application of relaxation coping skills were under-           the response-produced cues of anxiety with relaxation,
scored as the cornerstones of maintaining gains. The          leading to the development of a new self-managed cop-
client contracted to continue self-monitoring and AMT         ing habit pattern.
application through at least the next four months. She           Although some AMT procedures may appear similar to
developed a written contract and agreed to set aside $1       other behavior therapy methods using relaxation, there
per day toward the purchase of new clothes for every          are several distinguishing characteristics of AMT. AMT
day she managed her anxiety and stress as well as an          initiates anxiety arousal during sessions rather than min-
additional $5 for a week in which she did so every day.       imizing it as in desensitization. The goal of arousal is not
The client mailed in her self-monitoring logs every two       extinction, but the opportunity to attend to the internal
weeks. These were followed by therapist phone calls to        cues of anxiety arousal and to practice relaxation for
                                                  Anxiety Management Training                                           67
anxiety reduction. AMT uses homework to ensure trans-             length is also difficult to standardize during group ses-
fer of training. Homework requires that clients apply re-         sions because clients might signal anxiety after differ-
laxation coping skills in vivo. This practice ensures that        ent intervals of visualization. Therefore, in the initial
skills acquired in therapy are transferred to real-life situa-    sessions, the anxiety scenes should be visualized for 30
tions outside of treatment. Self-control is also empha-           to 60 seconds, with timing started after approximately
sized. AMT actively fosters self-management by gradually          half of the group has signaled anxiety. In group applica-
requiring clients to assume more and more responsibility.         tions, it is likely that clients will report various other
Early in treatment therapists provide a great deal of con-        sources of emotional distress (e.g., anger, guilt, embar-
trol over both anxiety arousal and relaxation retrieval.          rassment, depression, etc.). Therefore, it is important
However, clients gradually assume these responsibilities.         to make sure that clients apply relaxation to all sources
Therapeutic instructions, fading of therapist control, and        of emotional distress. Often the final two to three ses-
homework assignment help clients develop skills that              sions are used to focus on other emotionally distressing
increase their ability to control their anxiety. Because of       scenes in order to provide clients with in-session prac-
the self-control element, AMT often leads to increased            tice in dealing with such emotional issues.
self-efficacy.
                                                                     Applications—Anxiety Conditions. Originally, AMT
                                                                  was developed and evaluated for use with chronically
                IV. APPLICATIONS                                  stressed and anxious individuals and for GAD. Over
                AND EXCLUSIONS                                    the years, there has been empirical support for its use
                                                                  with other anxiety conditions such as panic disorder,
   Applications—Group AMT. AMT may be employed                    PTSD, simple and social phobias, multiple sources of
with individuals or groups. Groups can be relatively              anxiety and stress (e.g., an individual who is dealing
similar in their source of anxiety (e.g., groups of social        with both work- and heath-related stress), generally
phobics) or quite heterogeneous with widely differing             anxious and stressed medical outpatients, and anxiety-
sources of anxiety and stress. Group size should proba-           or stress-related health issues such as Type A behavior,
bly be limited to about eight. Research suggests that             tension headaches, diabetes, dysmenorrhea, and essen-
groups of over 25 are ineffective.                                tial hypertension. AMT has also proven helpful to indi-
   Group AMT requires several modifications from indi-             viduals who experience performance-related anxiety
vidual AMT. Therapy session duration should be ex-                (e.g., anxiety that interferes with athletic performance,
tended by 20 to 30 minutes per session in order to                public speaking, or music recitals), even if the anxiety
attend to the increased number of clients and their vari-         level is not sufficient to be diagnosed a phobic disorder.
ous issues. If the treatment session cannot be length-            AMT has also been adapted to high general anger and
ened, then the number of sessions should be lengthened            situation-specific angers such as anger while driving.
to accommodate clients. Although individual AMT uses
homework to develop both relaxation and anxiety                      Applications—Integration with Other Interventions.
scenes, this is particularly important in groups, if time is      The coping skills in AMT can serve as one treatment
to be used efficiently. That is, clients must come to the          component in complex treatment plans. For example,
early sessions with proposed scenes outlined in detail,           depressive disorders are often mixed with anxiety, ten-
so that group discussion time is saved for shaping up or          sion, and worry. In such cases, a treatment plan could
crystallizing scene content. Since scene content varies           rely on AMT to address anxiety and could be followed
across clients in group AMT, the therapist cannot pro-            by other psychological and biological interventions for
vide detailed descriptions of the scene in order to stim-         the depressive disorder. Some studies using AMT to
ulate visualization and anxiety arousal.                          treat anxiety report that depression also declined. Pos-
   Group clients are asked to bring two scenes to each            sible reasons include the tendency for anxiety and de-
session, which are labeled “anxiety scene 1” and “anxi-           pression to be correlated, or the reduction of
ety scene 2.” Anxiety is elicited by giving the general           depression due to the increase in efficacy from AMT.
instruction for clients to visualize “your first” or “your            AMT is easily included as an element of other psy-
second anxiety scene.” Scenes are alternated by refer-            chological interventions. For example, AMT-like inter-
ring to the first or second anxiety scene, and clients are         ventions have been successfully combined with
instructed that if one scene is not eliciting anxiety they        cognitive restructuring in the treatment of GAD, panic
are to continue to visualize the one that does. Exposure          disorder, social phobia, Type A behavior, and anger.
68                                             Anxiety Management Training

AMT has also been effectively combined with cognitive          pectancies. However, if this issue cannot be resolved,
and behavioral interventions in the treatment of voca-         other interventions should be employed.
tionally anxious individuals.                                     Few studies have been reported concerning the effec-
   AMT may be used as an initial step to enable clients        tiveness of AMT with children and the elderly. How-
to respond to other psychotherapeutic interventions.           ever, anecdotal evidence has shown that ethnic
For example, AMT might be used with a sexually                 minority youth can respond to AMT and that children
abused client. Providing anxiety management skills             can develop relaxation skills and use imagery.
may facilitate clients’ ability to discuss and confront
emotionally charged topics. Another potential applica-
tion of AMT is in prevention or simply as a general cop-                     V. EMPIRICAL STUDIES
ing skill for daily life stresses.
   In summary, AMT can be a valuable part of an over-             Many studies support the efficacy of AMT. In 1990
all treatment plan. In integrated interventions it is sug-     Richard Suinn reviewed the literature and concluded
gested that AMT be implemented as the first step. It            AMT to be effective with a wide variety of disorders.
helps the client achieve anxiety reduction skills while           AMT is effective with various phobias and situa-
at the same time building the therapeutic relationship         tional anxieties. For example, AMT reduced social,
and alliance. It can also reduce resistance to con-            math, test, and public speaking anxieties, and in some
fronting anxiety-related therapeutic content, content          cases improved performance in these areas as well. A
that might be essential for other psychotherapeutic in-        more recent study showed that both AMT and a cogni-
terventions. Since a side benefit of AMT is an increase         tive intervention lowered math anxiety and improved
in self-efficacy, possibly due to the self-control that is      math performance in math-anxious college students.
achieved, clients might feel more confident when fac-           Anxiety surrounding vocational indecision was re-
ing other personal-emotional problem areas.                    duced by AMT as well. Throughout these studies, AMT
                                                               was as effective as or more effective than other inter-
   Exclusions and Contraindications. Few contraindica-         ventions such as systematic desensitization, self-con-
tions for AMT have been identified. The AMT model               trol desensitization, systematic rational restructuring,
suggests several treatment considerations. AMT is an           social skill building, and vocational counseling. More-
intervention that requires clients who have the cogni-         over, although AMT targeted specific phobias or anxi-
tive-attentional processes and motivation necessary for        eties, reductions of general anxiety were reported in
performing its procedures. Clients must be able to fol-        several studies, suggesting that AMT was associated
low instructions, develop and maintain anxiety im-             with response generalization.
agery, and follow through on homework assignments.                High trait anxiety, GAD, panic and posttraumatic
Individuals who cannot or are unwilling to engage in           stress disorder have also been treated successfully with
these activities are not good candidates for AMT. For          AMT. Effects were maintained at long-term followup,
example, a small number of individuals have great dif-         and, where measured, generalized effects were found
ficulty in visualizing events. An alternative interven-         on measures of depression and anger. AMT lowered
tion is required such as in vivo presentation of               anxiety levels and use of anxiety medications in a
anxiety-arousing situations.                                   group of GAD and panic-disordered psychiatric pa-
   AMT is based on clients’ readiness to develop self-         tients. AMT and cognitive therapy lowered anxiety in
control over their anxieties. Some clients do not hold         outpatients with GAD and tended to be more effective
such self-control expectancies and may prefer treat-           than psychodynamic therapy. Also, AMT reduced anxi-
ments involving minimal personal behavior change               ety, avoidance, and intrusions of trauma-related memo-
(e.g., anti-anxiety medication). Therapists must ad-           ries in Vietnam veterans with posttraumatic stress
dress client expectations about treatment goals and            disorder. In addition, general anxiety, ratings of anger
techniques before AMT is adopted.                              and anxiety, and overall psychiatric status were im-
   Research suggests that some individuals develop re-         proved in schizophrenic outpatients receiving AMT.
laxation-induced anxiety (i.e., relaxation training in-           Stress- and medically related conditions have also
creases rather than reduces anxiety). Sometimes, this          responded favorably to AMT. For example, AMT has
problem can be resolved by repeated practice of small          lowered Type A behavior and general anxiety in Type
relaxation training steps, a switch to an alternative re-      A individuals, blood pressure levels in individuals
laxation training methodology, or counter-demand ex-           with essential hypertension, stress in individuals with
                                               Anxiety Management Training                                                69
diabetes, gynecological symptoms and general anxiety           ation retrieval. However, over time and with client suc-
in women with dysmenorrhea, and stress in gynecol-             cess in anxiety management, the therapist assistance is
ogical outpatients. Again, AMT tended to be as effec-          faded to client self-control, and the level of anxiety
tive as other interventions and, where assessed, to            arousal is increased. Homework assignments involve
show long-term maintenance.                                    applying relaxation coping skills outside of the treat-
   AMT has also been successfully adapted to anger re-         ment sessions to ensure transfer of relaxation coping
duction. The procedures of AMT have been success-              skills to real-life application. Portions of latter sessions
fully adapted to control general anger and anger while         address issues of maintenance and relapse prevention
driving. In these studies, the adaptation of AMT was           and may address application to other distressing emo-
generally as effective as cognitive and combined cogni-        tions as well. AMT is empirically supported with many
tive-relaxation interventions.                                 anxiety- and stress-related disorders and conditions.
   In summary, AMT is an empirically supported inter-          AMT may be employed as a stand-alone intervention or
vention. It is effective with situational anxiety and pho-     be integrated with other behavioral and nonbehavioral
bic conditions, as well as GAD, general anxiety, and           interventions in a comprehensive treatment plan.
posttraumatic stress disorder. It is also effective with
stress-related medical conditions and anger. Where
comparisons have been made to other interventions, it                 See Also the Following Articles
is generally significantly more effective than control          Anxiety Disorders: Brief Intensive Group Cognitive Behavior
conditions, and as effective as certain other cognitive-       Therapy I Applied Relaxation I Applied Tension I
behavioral interventions. Where long-term follow-ups           Aversion Relief I Biofeedback I Complaints Management
have been conducted, effects were well maintained. In          Training I Panic Disorder and Agoraphobia I Progressive
all, there is a solid empirical literature supporting AMT.     Relaxation I Relaxation Training
Moreover, since many of the outcome studies of AMT
have been conducted in a group format, there is con-
siderable support for group AMT as well.                                          Further Reading
                                                                       .
                                                               Daley, P C., Bloom, L. J., Deffenbacher, J. L., & Steward, R.
                                                                 (1983). Treatment effectiveness of anxiety management
                  VI. SUMMARY                                    training in small and large group formats. Journal of Coun-
                                                                 seling Psychology 30, 104–107.
   Anxiety management training (AMT) is a brief be-            Durhan, R. C., Murphy, T., Allan, T., Richard, K., et al.
havioral intervention involving the use of relaxation as         (1994). Cognitive therapy, analytic psychotherapy, and
a skill for reducing anxiety. It may be conducted indi-          anxiety management training for generalised anxiety dis-
vidually or in small groups, and it typically takes about        order. British Journal of Psychiatry 165, 315–323.
eight sessions. AMT is founded on the principle that           Pantalon, M. V., & Motta, R. W. (1998). Effectiveness of anx-
anxiety has stimulus properties that can serve as cues           iety management training in the treatment of posttrau-
for relaxation as a coping response. AMT relies on relax-        matic stress disorder: A preliminary report. Journal of
                                                                 Behavior Therapy and Experimental Psychiatry 29, 21–29.
ation training, in-session anxiety arousal through im-
                                                               Suinn, R. M. (1996). Anger: A disorder of the future, here
agery and practice of relaxation as a coping skill, and
                                                                 today. The Independent Practitioner 16, 149–151.
graduated homework assignments to ensure transfer for          Suinn, R. M. (1990). Anxiety Management Training: A Behav-
real-life anxiety reduction. The first session is devoted         ior Therapy. Plenum Press, New York.
primarily to relaxation practice and anxiety scene devel-      Suinn, R. M. (1975). Anxiety management training for gen-
opment. The next seven sessions are devoted to eliciting         eral anxiety. In Suinn, R., and Weigel, R. (Eds.). The Innov-
anxiety through anxiety-arousing imagery and initiating          ative Psychological Therapies: Critical and Creative
relaxation coping skills for anxiety reduction. In early         contributions, pp. 66–70, Harper and Row, New York.
sessions, anxiety arousal is moderate, and the therapist       Suinn, R. M., & Deffenbacher, J. L. (1988). Anxiety manage-
provides considerable structure and assistance in relax-         ment training. The Counseling Psychologist 16, 31–49.
                                Applied Behavior Analysis
                                                       Alan E. Kazdin
                                                           Yale University




    I.   Description of Treatment                                        sponse is consistently performed in the presence of the SD
   II.   Theoretical Bases                                               but not in the presence of the S∆.
 III.    Essential Features of Applied Behavior Analysis              discrimination Responding differently in the presence of dif-
  IV.    Empirical Studies                                               ferent cues or antecedent events; control of behavior by
   V.    Applications                                                    discriminative stimuli.
  VI.    Issues and Challenges                                        discriminative stimulus (SD) An antecedent event or stimulus
 VII.    Summary                                                         that signals that a certain response will be reinforced. A re-
         Further Reading                                                 sponse is reinforced in the presence of an SD. After an
                                                                         event becomes an SD by being paired with reinforcement,
                                                                         its presence can increase the probability that the response
                                                                         will occur.
                            GLOSSARY                                  experimental design The plan for evaluating whether the in-
                                                                         tervention, rather than various extraneous factors, was re-
antecedents Stimuli, settings, and contexts that occur before            sponsible for behavior change.
   and influence behaviors. Examples include instructions              extinction A procedure in which the reinforcer is no longer
   and gestures from others.                                             delivered for a previously reinforced response.
baseline rate The frequency with which behavior is per-               functional analysis Evaluation of the behavior and of an-
   formed prior to initiating a behavior modification pro-                tecedent and consequences associated with the behavior. A
   gram; operant rate of behavior.                                       functional analysis identifies the “causes” of behavior, that
behavior Any observable or measurable response or act.                   is, current conditions that are maintaining the behavior.
consequences Events that follow behavior and may include                 These conditions are determined by directly assessing be-
   influences that increase, decrease, or have no impact on               havior, proposing hypotheses about likely factors that are
   what the individual does.                                             controlling behavior, and testing these hypotheses to
contingency The relationship among antecedents (e.g.,                    demonstrate the conditions that cause the behavior. The
   prompts, setting events), a behavior (the response to be              information from functional analysis is then used to guide
   changed), and consequences (e.g., reinforcers).                       the intervention by direct alteration of conditions so that
contingent on behavior An event (e.g., praise, tokens, time              the desired behaviors are developed.
   out) is contingent on behavior when the event is delivered         functional relation The relation of behavior and an
   only if that behavior is performed.                                   experimental condition or contingency. A functional
differential reinforcement Reinforcing a response in the pres-           relation is demonstrated if behavior systematically
   ence of one stimulus (SD) and extinguishing the response              changes when the contingency is applied, withdrawn,
   in the presence of other stimuli (S∆). Eventually, the re-            and reapplied.




Encyclopedia of Psychotherapy                                                                        Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                         71                                                      All rights reserved.
72                                                     Applied Behavior Analysis

multiple-baseline design An experimental design that dem-             S∆ An antecedent event or stimulus that signals that a certain
   onstrates the effect of a contingency by introducing the              response will not be reinforced.
   contingency across different behaviors, individuals, or sit-       schedule of reinforcement The rule denoting how many or
   uations at different points in time. A causal relationship            which responses will be reinforced.
   between the experimental contingency and behavior is               SD See discriminative stimulus.
   demonstrated if each of the behaviors changes only when            setting events Antecedent events that refer to context, condi-
   the contingency is introduced.                                        tions, or situational influences that affect the contingencies
negative reinforcement An increase in the likelihood or prob-            that follow. Such events set the stage for behavior-conse-
   ability of a response that is followed by the termination or          quence sequences that are likely to occur.
   removal of a negative reinforcer.                                  shaping Developing a new behavior by reinforcing successive
operant Behavior that is emitted rather than elicited. Emit-             approximations toward the terminal response.
   ted behavior operates on the environment and responds              single-case experimental designs Arrangements for evaluat-
   to changes in consequences (e.g., reinforcement, punish-              ing whether the intervention was responsible for change.
   ment) as well as antecedents (e.g., setting events,                   The designs require continuous assessment of the target
   stimuli).                                                             behavior(s) over time and changes in how and sometimes
operant conditioning A type of learning in which behaviors               to whom or when the intervention is applied. The unique
   are influenced primarily by the consequences that follow               feature of the designs is that they permit causal inferences
   them. The probability of operant behaviors is altered by              to be drawn about interventions as applied to the individ-
   the consequences that they produce. Antecedents too are               ual case.
   involved in learning as cues (SD, S∆) become associated            spontaneous recovery The temporary recurrence of a behavior
   with different consequences and can influence the likeli-              during extinction. A response that has not been reinforced
   hood of the behavior.                                                 may reappear temporarily during the course of extinction.
operational definition Defining a concept (e.g., aggression,            stimulus control The presence of a particular stimulus serves
   social skills) by referring to the specific operations that            as an occasion for a specific response. The response is
   are to be used for assessment. The “operations” or meth-              performed only when it is in the presence of a particular
   ods of measuring the construct constitute the operational             stimulus.
   definition.                                                         target behavior The behavior to be altered or focused on dur-
positive opposite A behavior that is an alternative to and               ing the intervention. The behavior that has been assessed
   preferably incompatible with the undesired behavior. Sup-             and is to be changed.
   pression or elimination of an undesirable behavior can be          time out from reinforcement A punishment procedure in
   achieved or accelerated by reinforcing a positive opposite.           which access to positive reinforcement is withdrawn for a
   When the goal is to reduce or eliminate behavior, it is help-         brief period contingent on behavior. Isolation from a group
   ful to consider the positive opposite behaviors that are to           exemplifies time out from reinforcement, but many varia-
   be developed in its stead.                                            tions do not require removing the client from the situation.
positive reinforcement An increase in the likelihood or proba-        token A tangible object that serves as a reinforcer. Poker
   bility of a response that is followed by a positive reinforcer.       chips, coins, tickets, stars, points, and check marks are
positive reinforcer An event whose presentation increases the            commonly used as tokens. They derive their value from
   probability of a response that it follows.                            being exchangeable for multiple backup reinforcers.
prompt An antecedent event that helps initiate a response.            token economy A reinforcement system in which tokens are
   Instructions, gestures, physical guidance, and modeling               earned for a variety of behaviors and are used to purchase a
   cues serve as prompts.                                                variety of backup reinforcers.
punishment Presentation of an aversive event or removal of a          transfer of training The extent to which the changes in be-
   positive event contingent on a response that decreases the            havior during and after the program extend to settings, sit-
   likelihood or probability of the response.                            uations, or circumstances that were not included in the
reinforcement An increase in the likelihood or probability of            program.
   a response when the response is immediately followed by a
   particular consequence. The consequence can be either the
   presentation of a positive reinforcer or the removal of a                I. DESCRIPTION OF TREATMENT
   negative reinforcer.
response cost A punishment procedure in which a positive                 Applied behavior analysis is a specific area of re-
   reinforcer is lost contingent on behavior. With this proce-
                                                                      search and intervention within behavior modification.
   dure, unlike time out from reinforcement, no time limit to
                                                                      Several characteristics of behavior modification include
   the withdrawal of the reinforcer is specified. Fines and loss
   of tokens are common forms of response cost.                       an emphasis on overt behavior, a focus on current de-
response maintenance The extent to which changes in behav-            terminants of behavior, and reliance on the psychology
   ior are sustained after the program or the intervention            of learning as the basis for conceptualizing clinical
   phase is ended.                                                    problems (e.g., anxiety, depression) and their treat-
                                                 Applied Behavior Analysis                                                73
ment. The psychology of learning refers broadly to the-          in response to a loud noise or squinting in response to
ory and research derived from different types of learning,       bright light. Reflex responses are unlearned and are
including classical conditioning, operant conditioning,          controlled by eliciting stimuli. Most of the behaviors
and observational learning (modeling). Applied behav-            performed in everyday life are operants. Examples in-
ior analysis draws primarily on operant conditioning as          clude reading, walking, working, talking, nodding
the basis for developing interventions.                          one’s head, smiling, and other freely emitted responses.
   Applied behavior analysis is not a technique or in-           Operant conditioning is the type of learning that elabo-
deed even a set of techniques. Rather, it is an approach         rates how operant behaviors develop and the many
toward conceptualizing, assessing, and evaluating be-            ways in which their performance can be influenced.
havior and devising interventions to effect behavior                Beginning in the 1930s, Skinner’s animal laboratory
change. The interventions focus on antecedents, behav-           work elaborated the nature of operant conditioning, in-
iors, and consequences and how these can be altered to           cluding the lawful effects of consequences on behavior.
influence behavior. What is particularly remarkable is            These lawful effects generated various principles of op-
the scope of applications that have derived from applied         erant conditioning, highlighted in Table 1. These prin-
behavior analysis. Apart from applications to many clin-         ciples provide general statements about the relations
ical problems seen in treatment, interventions have fo-          between behavior and environmental events. Basic ex-
cused on a vast array of behaviors in everyday life. This        perimental and animal laboratory research has contin-
contribution describes applied behavior analysis, the            ued to flourish and is referred as the experimental
underlying principles and techniques, central features           analysis of behavior. The principles have also served as
of the approach to assessment and evaluation, and how            the basis for developing interventions in applied set-
treatment and evaluation are intertwined.                        tings such as the home, school, hospitals and institu-
                                                                 tional settings, business and industry, and the
                                                                 community at large. The application and evaluation of
             II. THEORETICAL BASES                               interventions derived from basic research on operant
                                                                 conditioning has emerged as its own area of research
   The underpinnings of applied behavior analysis de-            and is referred to as applied behavior analysis.
                          .
rive from the work of B. F Skinner (1904–1990), who                 Laboratory work on the study of operant condition-
developed and elaborated operant conditioning, a type            ing was characterized by a focus on overt behavior, as-
of learning that emphasizes the control that environ-            sessment of the frequency of behavior over time, and
mental events exert on behavior. The behaviors are re-           the study of one or a few organisms (e.g., rats, pigeons)
ferred to as operants because they are responses that            at a time. The focus on one or two organisms over time
operate (have some influence) on the environment.                 permitted the careful evaluation of how changes in
Operant behaviors are strengthened (increased) or                consequences influenced performance and the lawful-
weakened (decreased) as a function of the events or              ness of behavior under diverse circumstances. Eventu-
consequences that follow them. Operants can be distin-           ally, the approach was extended to humans. The initial
guished from reflex responses, such as a startle reaction         goal was to see if lawful relations between behavior and


                                                      TABLE 1
                                  Summary of Key Principles of Operant Conditioning

Principle                                           Relation between environmental events and behavior

Reinforcement               Presentation or removal of an event after a response that increases the likelihood or
                              probability of that response.
Punishment                  Presentation or removal of an event after a response that decreases the likelihood or
                              probability of that response.
Extinction                  No longer presenting a reinforcing event after a response that decreases the likelihood
                              or probability of the previously reinforced response.
Stimulus control and        Reinforcing the response in the presence of one stimulus but not in the presence of another.
   discrimination             This procedure increases the likelihood or probability of the response in the presence of the
                              former stimulus and decreases the likelihood or probability of the response in the presence of
                              the latter stimulus.
74                                              Applied Behavior Analysis

consequences demonstrated in animal laboratory re-                          A. Contingencies: The ABCs
search could be replicated in laboratory studies with                               of Behavior
humans and to investigate how special populations
(e.g., adult psychiatric patients, mentally retarded chil-        Behavior change in applied behavior analysis is
dren) responded.                                               achieved by altering the contingencies of reinforce-
   By the late 1950s and early 1960s, operant condition-       ment. The contingencies refer to the relationships be-
ing methods were extended to human behavior outside            tween behaviors and the environmental events that
the laboratory and focused on behaviors that were more         influence behavior. Three components are included in
relevant to everyday life. Initial demonstrations were         a contingency, namely, antecedents (A), behaviors (B),
conducted merely to see if environmental consequences          and consequences (C). The notion of a contingency is
could influence behavior outside of the context of a lab-       important not only for understanding behavior but
oratory task. For example, could the irrational speech of      also for developing programs to change behavior. An-
psychiatric patients or interpersonal interactions of such     tecedents refer to stimuli, settings, and contexts that
patients with the staff be influenced by systematically         occur before and influence behaviors. Examples in-
providing attention and praise for positive, prosocial be-     clude verbal statements, gestures, or assistance in ini-
havior? Several dramatic demonstrations in the early           tiating the behavior. Behaviors refer to the acts
1960s showed that marked behavior changes could be             themselves, what individuals do or do not do, and the
achieved. These demonstrations were unique because             actions one wishes to develop or change. Conse-
they included extensions of procedures developed in            quences refer to events that follow behavior and may
laboratory research, systematically applied conse-             include influences that increase, decrease, or have no
quences to develop behavior, carefully assessed behavior       impact on what the individual does. Table 2 illustrates
to evaluate the immediate effects of consequences, and         the three components of a contingency with simple
demonstrated experimental control of the consequences.         examples from everyday life.
Experimental control was evident by showing that be-              Antecedents include a number of potential influ-
haviors (e.g., delusional speech of psychiatric patients)      ences on behavior. Setting events are one category of
could be increased and decreased as a function of sys-         antecedents and refer to contextual factors or condi-
tematically altering consequences in the environment           tions that influence behavior. They are broad in scope
(e.g., staff attention and praise). Of course, the control     and set the stage for the behaviors and consequences
did not mean or imply that all behaviors could be influ-        that follow. Examples include features of the situation,
enced by environmental events or that current influ-            features of the task or demands presented to the indi-
ences in the environment are the only causes of                vidual, conditions within the individual (e.g., exhaus-
behavior. However, the early demonstrations raised the         tion, hunger, expectations of what will happen), or
prospect that one way to intervene on many behaviors           behaviors of others that influence the likelihood of spe-
would be to alter antecedents and consequences and to          cific behaviors that follow. For example, stress at work
do so in a systematic way. Laboratory research provided        can influence the subsequent behavior of an individual
guidelines on how this might be accomplished. The              when he or she returns home at the end of the day. The
early extensions of operant conditioning principles to         stress may influence interactions at home and reactions
human behavior began an area of research that is now           to other events (e.g., comments from a spouse, “bad”
formally recognized as applied behavior analysis.              habits of a spouse). Setting events are important influ-
                                                               ences on behavior. The “same” request delivered to a
                                                               child may lead to quite different responses depending
       III. ESSENTIAL FEATURES OF                              on how the request is delivered, when, and in the con-
      APPLIED BEHAVIOR ANALYSIS                                text of other influences. Prompts are another type of
                                                               antecedent event and refer to specific antecedents that
   Applied behavior analysis is an approach to interven-       directly facilitate performance of behavior. They are
tion. The approach is characterized by attention to a spe-     distinguished from setting events, which are more con-
cific set of influences and how they can be used to              textual, indirect, and broader influences. Common ex-
develop behavior as well as methods of assessment and          amples of prompts include instructions to engage in
evaluation. It is useful to describe these substantive and     the behavior (e.g., “Please wash up before dinner”),
methodological components separately before convey-            cues (e.g., reminders or notes to oneself, lists of things
ing how they are intertwined.                                  to do), gestures (e.g., to come in or leave the room), ex-
                                                  Applied Behavior Analysis                                                75
                                                       TABLE 2
                         Three Components of a Contingency and Illustrations from Everyday Life

Antecedent                                                    Behavior                              Consequence

Telephone rings                                       Answering the phone                 Voice of person at the other end
Wave (greeting) from a friend                         Walking over to the friend          Visiting and chatting
Parent instruction to a child to clean the room       Picking up toys                     Verbal praise and a pat on the back
Warning not to eat spoiled food                       Eating the food                     Nausea and vomiting




amples and modeling (e.g., demonstrations to show                  instances of compliance. The example is helpful in an-
this is how the behavior, task, or skill is performed),            other way. For a very noncompliant child, there may
and physical guidance (e.g., guiding a person’s hands to           be no instances of the performance to praise. The use
show her how to play a musical instrument).                        of antecedents to prompt compliance (e.g., prompts of
   Behavior, the second part of the contingencies of re-           precisely what the child could say), shaping to approx-
inforcement, refers to what an individual does and the             imate compliance (e.g., partial compliance to simple
goal of the program, that is, what one wants the indi-             requests), and praise contingent on performance can
vidual to do. The goal of the intervention may be to in-           readily develop the behavior.
crease performance in some way (e.g., initiating a                    The principles of operant conditioning include the
behavior that never occurs, developing more frequent               many ways in which consequences follow behavior.
performance of behavior that is occurring, fostering               The principles can be translated into a very large
longer periods or more consistent performance of the               number of techniques. For example, positive rein-
behavior, or fostering the behavior in new situations).            forcement was mentioned as a principle (Table 1).
In these instances, providing antecedents and conse-               The positive consequences that can be applied contin-
quences may be sufficient to increase or extend the be-             gently to alter behavior can include food, praise, at-
havior. In many other cases, the individual does not               tention, feedback, privileges, and activities. Indeed,
have the behavior in his or her repertoire or only has             often many of these are combined into a single rein-
the behavior partially. The desired behavior may be so             forcement program where the individual can earn to-
complex (e.g., driving a car, reading a story) that the el-        kens (e.g., points, starts, tickets, or money) contingent
ements making up the response are not in the reper-                on the desired behavior. The tokens are then used to
toire of the individual. In these cases, one cannot                purchase a variety of other reinforcers available in the
merely wait for the behavior to occur and provide con-             setting. Many reinforcers (praise, attention, tokens)
sequences; the response may never occur. The behavior              have broad applicability across many individuals and
can be achieved by reinforcing small steps or approxi-             generally are effective. However, individual prefer-
mations toward the final response, a process referred to            ences and special features of the situation (e.g., at
as shaping.                                                        home, at school) can be readily incorporated into a
   Consequences, the third component of the contin-                behavior-change program.
gencies, refers to what follows behavior. For a conse-                Providing positive reinforcers after behavior can
quence to alter a particular behavior, it must be                  have a potent effect. Yet, identifying the reinforcers that
dependent or contingent on the occurrence of that be-              might be used can oversimplify the task of changing
havior. Behavior change occurs when certain conse-                 behavior. To be effective, the consequences must be
quences are contingent on performance. A                           provided in special ways; these ways have been well
consequence is contingent when it is delivered only                studied in research. Merely providing some positive
after the desired behavior has been performed and is               consequence for behavior is not likely to achieve
otherwise not available. When a consequence is not                 changes unless several conditions are in place. Table 3
contingent on behavior, this means that it is delivered            conveys several conditions that influence the effective-
independently of what the person is doing. For exam-               ness of reinforcement.
ple, praise might be used to increase the compliance of               Although it is useful to distinguish antecedents, be-
an oppositional child. To exert influence, praise would             havior, and consequences, they are interrelated. An-
need to be contingent on performance, in this case on              tecedent events (e.g., setting events and prompts) often
76                                                 Applied Behavior Analysis

                         TABLE 3                                  control. When there is stimulus control, the presence
Factors in the Delivery of Reinforcement That Influence            of a stimulus increases the likelihood of a response.
                   Effects on Behavior                            The presence of the stimulus does not cause or auto-
                                                                  matically elicit the response but rather merely increases
Contingent Application of Consequences                            the probability that a previously reinforced behavior
  The reinforcer is provided only if the desired response is      will occur.
  performed and otherwise not given.                                 Instances of stimulus control pervade everyday life.
Delay of Reinforcement                                            For example, the sound of a doorbell signals that a
  The reinforcer should be delivered immediately after the        certain behavior (opening the door) is likely to be re-
  desired behavior.                                               inforced (by seeing someone). Specifically, the sound
Magnitude or Amount of the Reinforcer                             of the bell frequently has been associated with the
  Larger magnitude reinforcers (e.g., quantity of food, num-
                                                                  presence of visitors at the door (the reinforcer). The
  ber of points, amount of money) increase effectiveness of
                                                                  ring of the bell (SD) increases the likelihood that the
  reinforcement, up to a point that the individual might be
  satiated (e.g., if food is used).                               door will be opened. In the absence of the bell (S∆),
Quality or Type of the Reinforcer                                 the probability of opening the door for a visitor is very
  Reinforcers that are highly preferred lead to greater per-      low. The ring of a doorbell, telephone, alarm, and
  formance than do those that are less preferred.                 kitchen timer all serve as discriminative stimuli (SD)
Schedule of Reinforcement                                         and signal that certain responses are likely to be rein-
  When behavior is being developed, reinforcement after           forced. Hence, the probability of the responses is in-
  every occurrence of the response (continuous reinforce-         creased. In a quite different context, when a robber
  ment) is much more effective than reinforcement for only        confronts us, this is not an SD for really friendly and
  some of the responses (intermittent reinforcement).             social behaviors on our part. The cues that robbers
                                                                  present (weapon, hostile demeanor, outfit, context)
                                                                  suggest that probably only one response will be rein-
                                                                  forced (e.g., compliance).
                                                                     Stimulus control and discrimination illustrate how
become associated with a particular behavior and its              antecedents, behaviors, and consequences become
consequences. For example, in some situations (or in              connected. In applied behavior analysis, often the goal
the presence of certain stimuli), a response may be re-           is to develop behavior in some situations (e.g., at
inforced, whereas in other situations (in the presence            home) or in multiple situations. Usually, it is impor-
of other stimuli), the same response may not be rein-             tant to develop behavior, so it transfers across many
forced. The concept of differential reinforcement is cen-         stimulus conditions; this can be accomplished during
tral to understanding stimulus events and their                   training, as mentioned later in this entry.
influence. Differential reinforcement refers to reinforc-
ing a response in the presence of one stimulus or situa-
tion and not reinforcing the same response in the
                                                                                    B. Assessment
presence of another stimulus or situation. When a re-                Implementing an intervention requires clearly stating
sponse is consistently reinforced in the presence of a            the goal, carefully describing the behaviors that are to
particular stimulus (e.g., at home) and not reinforced            be developed, and measuring these before the program
in the presence of another stimulus (e.g., at school),            begins. The main goal of a program is to alter or develop
each stimulus signals the consequences that are likely            a particular behavior, referred to as the target behavior.
to follow. A stimulus whose presence has been associ-             There might well be multiple target behaviors.
ated with reinforcement is referred to as a discrimina-              Identifying the goal of the program in most cases
tive stimulus (SD). A stimulus whose presence has been            seems obvious and straightforward because of the di-
associated with nonreinforcement is referred to as a              rect and immediate implications of the behavior for the
nondiscriminative stimulus or (S∆ or S delta). The ef-            adjustment, impairment, and adaptive functioning of
fect of differential reinforcement is that eventually the         the individual in everyday life. For example, many in-
reinforced response is likely to occur in the presence of         terventions have decreased such behaviors as self-in-
the SD but unlikely to occur in the presence of the S∆.           jury (e.g., headbanging) among autistic children,
When responses are differentially controlled by an-               anxiety and panic attacks, and driving under the influ-
tecedent stimuli, behavior is said to be under stimulus           ence of alcohol, and have increased such behaviors as
                                                Applied Behavior Analysis                                           77
engaging in practices that promote health (e.g., exer-         ally be observed, measured, and agreed upon by indi-
cise, consumption of healthful foods) and academic             viduals administering the program.
performance among individuals performing poorly at                The general complaint (e.g., the child has tantrums)
school.                                                        must be translated into operational definitions. Opera-
   More generally, behaviors are selected for interven-        tional definitions refer to defining a concept on the
tion for any of several reasons. First is impairment, or       basis of the specific operations used for assessment.
the extent to which an individual’s functioning in             Paper-and-pencil measures (questionnaires to assess
everyday life is impeded by a particular problem or set        the domain), interviews, reports of others (e.g., par-
of behaviors. Impairment consists of meeting role de-          ents, spouses) in contact with the client, physiological
mands at home, at school, and at work, interacting             measures (e.g., arousal, stress), and direct observation
prosocially and adaptively with others, and not being          are the among the most commonly used measures in
restricted in the settings, situations, and experiences        psychological research to operationalize key concepts.
in which one can function. Second, behaviors that are          Several measures might be selected in any given inter-
illegal or rule-breaking too are brought to treatment.         vention program, and no single measure can capture all
Illegal behaviors would include driving under the in-          components of the concept. In applied behavior analy-
fluence of alcohol, using illicit drugs, and stealing;         sis, emphasis is placed on direct observation of overt
rule-breaking that is not illegal might include a child        behavior because overt behavior is viewed as the most
leaving school repeatedly during the middle of the day         direct measure of the treatment focus. For example, if
or not adhering to parent-imposed curfew. Third, be-           tantrums are of interest, it is useful to observe the
haviors that are of concern to individuals themselves          tantrums directly and to see when they occur, under
or to significant others serve as the basis for seeking        what circumstances, and whether they change in re-
interventions. For example, parents seek interven-             sponse to an intervention.
tions for a variety of child behaviors that affect daily          Once the target behavior(s) is carefully defined, ob-
life but may or may not be severe enough to reflect            servations are made to collect data on the problem. The
impairment or rule-breaking. Examples might include            observations may be made by tallying their occurrence
toilet training, school functioning, and mild versions         within a period of time or recording whether or not
of other behaviors that, if severe, might lead to im-          they occurred in a particular time interval. The behav-
pairment. Finally, behaviors are focused on that may           ior is sampled on a continuous basis, usually daily or
prevent problems from developing. For example, pre-            multiple times per week. For example, if the goal is to
mature babies and children from economically disad-            increase the social behavior of a withdrawn psychiatric
vantaged environments are at risk for later school             patient, to develop completion of homework in an ado-
difficulties. Early interventions within the first             lescent with academic difficulties, or to increase the ac-
months and few years of life are intended to develop           tivity of an elderly person in a residential home, the
pre-academic behaviors and avert later school difficul-        specific target behaviors will be defined and assessed
ties. Also, developing behaviors to promote safety             directly. The purpose is to obtain the rate of perform-
(e.g., in business and industry or in the home) or             ance prior to the intervention, referred to as the base-
health are selected to prevent later problems.                 line rate. Because interventions are often conducted in
   A behavioral program usually begins with a state-           everyday settings, parents, teachers, and others may be
ment from someone that there is a problem or a need to         involved in the collection of this information. Careful
intervene to address a particular end. Global state-           assessment is central because the assessment data are
ments of behavioral problems are usually inadequate            used to make decisions about the treatment while the
for actually beginning an intervention. For example, it        intervention is in effect.
is insufficient to select as the goal alteration of aggres-
siveness, learning deficits, speech, social skills, depres-
                                                                        C. Functional Analysis: From
sion, psychotic symptoms, and self-esteem. Traits,
summary labels, and personality characteristics are too
                                                                         Assessment to Intervention
general to be of much use. Moreover, definitions of the            Functional analysis consists of a methodology of
behaviors that make up such general labels may be              identifying the relation of a target behavior to an-
idiosyncratic among different behavior-change agents           tecedents and consequences and using this information
(parents, teachers, or hospital staff). The target behav-      to select the intervention. “Functional” emphasizes
iors have to be defined explicitly so that they can actu-       identifying the functions of the behavior, that is, the
78                                                         Applied Behavior Analysis

                                                            TABLE 4
                              Hypothetical Examples of the Consequences or Purposes of Behaviors

Behavior                                                                 Outcomes that may maintain that behavior

Tantrum of a child                           Attention from a parent, extra time with the parents, reduction of parent’s arguing with
  before going to bed                          each other
Arguing or fighting with                      Affection and promises of life-long commitment that result from making up after the
  a spouse/partner                             fight, time away from the spouse as he or she walks out for a few days
Complaining                                  Attention and sympathy from others, not hearing the complaints of others, personal
                                               relief or stress reduction as a function of expressing unfortunate conditions
Attaining good grades in school              Praise from others, success, reduction in anxiety about failing

   Note: The functions of a behavior are usually determined on an individual basis so there is no single function that a particular behavior invari-
ably serves for all or even most individuals. Indeed, different behaviors can serve the same function for two individuals, and the same behavior
may serve different functions for two individuals.



purposes the behavior may serve in the environment or                        crease inappropriate or deviant behavior and to foster
the outcomes that maintain the behavior. Table 4 pro-                        appropriate, prosocial behavior. This is the interven-
vides some examples of behaviors and some of the                             tion phase of functional analysis. The purpose of this
functions the behaviors may serve. “Analysis” empha-                         phase is to put into place the condition that controls
sizes the careful assessment and systematic evaluation                       behavior to achieve a significant therapeutic change.
to isolate precisely the factors that control behavior.                         Consider, as an example, a child (Kathy, age 8) who
The analysis consists of obtaining data about the hy-                        frequently fought (physically) with her younger sister
pothesized purposes that the behavior may serve and                          (Mary, age 4). The parents wanted to eliminate fighting.
testing whether these purposes actually control or in-                       Both children were in the home from late afternoon
fluence behavior.                                                             (after school and day care) and were observed by the
   The elements of functional analyses are assessment,                       mother for several days from the afternoon until the
development and evaluation of hypotheses about fac-                          children’s bedtime. We asked the mother to chart two re-
tors that control behavior, and intervention. Initially,                     lated behaviors when the children were together (in the
assessment is designed to identify the relations of an-                      same room). The first behavior was fighting and in-
tecedents and consequences to the behavior of interest                       cluded arguing, shouting, and hitting. The second be-
and hence the purposes or functions of the behavior.                         havior was playing cooperatively or being together in an
This assessment is likely to suggest circumstances or                        activity without the above behaviors. We recorded these
stimulus conditions with which the behavior is associ-                       latter behaviors because developing positive opposite be-
ated. For example, the behavior may appear to be more                        haviors typically serves as the focus of interventions that
frequent at some times of the day rather than others,                        are stimulated by interests in decreasing deviant behav-
when some persons are present rather than others, and                        ior. The behaviors were observed using a frequency
when certain effects or consequences occur.                                  count, that is, merely tallying the occurrence of any in-
   The patterns raise hypotheses about what may be                           stance of the behavior. One minute of either behavior
maintaining or controlling behavior. If at all possible,                     was scored as an instance of that behavior.
the hypotheses are tested directly by assessing the tar-                        Table 5 includes two charts the mother was asked to
get behavior as various conditions are changed. The                          use to track fighting (Chart A) and playing coopera-
conditions in which the hypotheses are tested may be                         tively (Chart B). The purpose of using a chart was to
brief and transient merely to see if different conditions                    identify whether any patterns emerged and suggest the
systematically influence behavior. This is an experi-                         conditions that may contribute to the behavior. The en-
mental phase designed to evaluate if the controlling                         tries in the chart are samples and reflect some of the in-
conditions can be identified.                                                 formation collected from the mother. After several
   The information gained from manipulating condi-                           days, it appeared (from Chart A) that Kathy’s fighting
tions and from assessment under different conditions is                      with her sister occurred mostly during the following
used to help the client directly. Specifically, the condi-                    antecedent conditions: after school but before dinner,
tions shown to influence behavior are altered to de-                          in the presence of the mother when she was by herself,
                                                          Applied Behavior Analysis                                                          79
                                                        TABLE 5
        Charts to Record Fighting (Chart A) and Playing Cooperatively (Chart B)—Sample Entries from the Charts


Chart A    Episodes of Fighting
                                       Antecedents situation/setting
Time/day/date                           conditions/others present                                         Consequences

Monday, 3:45 P.M.                     Watching TV, no else home                    Separated children, sent Kathy to her room, read to
                                                                                     her for 15 min
Tuesday, 5:00 P.M.                    Playing on the computer                      Took Kathy to her room and talked with her about
                                                                                     playing better with her sister, talked about what
                                                                                     happened at school
Wednesday, 4:10 P.M.                  Playing on the computer                      Sent Kathy to her room and she showed me drawings
                                                                                     and a poem she made at school.

   Note: The behavior observed is the fighting of Kathy with her younger sister. Any entry (row) on the chart refers to a time in which an episode
of fighting with her younger sister.


Chart B    Episodes of Playing Cooperatively
                                               Antecedents situation/setting
Time/day/date                                   conditions/others present                                          Consequences

Monday, 7:00 P.M.                    Watching TV; Bill (husband) and I watching                            None
                                      with them
Tuesday, 4:00 P.M.                   Watching TV; Marge (neighbor) in the kitchen                          None
                                      with me
Thursday, 7:30 P.M.                  Watching TV; no one else present                                      Watched until bath time and
                                                                                                            then went to bed

   Note: The behavior observed was playing cooperatively, that is, together in the same room and without fighting. Any entry (row) on the chart
refers to a time (5 minutes or more) in which the sister played cooperatively.




and when the girls were playing a game or watching                          mother was a positive reinforcer that inadvertently
television together. The consequences usually con-                          contributed to or maintained fighting. Kathy’s interest
sisted of the mother intervening to stop the fight, send-                    in attention from the mother, obviously “normal” for
ing Kathy to her room, and remaining in the room with                       any child, was heightened according to the mother,
Kathy until she calmed down. Chart B was rather inter-                      because of the strong sibling rivalry she had felt since
esting as well. Playing cooperatively was associated                        her younger sister was born. Also of interest were the
with the following antecedent conditions: the presence                      observations (Chart B) that playing cooperatively
of another adult in the home (the father or a neighbor                      among the two children was not systematically associ-
visiting the mother) and the time in which one or both                      ated with positive consequences.
parents were also in the room. No consequences sys-                            Based on the baseline observations of the target be-
tematically followed playing cooperatively. The parents                     haviors (fighting, playing cooperatively) and the use of
felt that they ought to leave well enough alone—a strat-                    the charts, we generated the following simple hypothe-
egy that is not helpful when one wants to develop spe-                      sis. Kathy’s fighting served to provide time alone with
cific behaviors. Here the undesired behavior was                            her mother. The fighting only occurred when the
positively reinforced (with attention, time with mom),                      mother was home without another adult because only
and the desired behavior was not.                                           on these occasions was the mother likely to provide the
   Using information from the charts, we hypothesized                       private and alone time with Kathy. That is, the mother
that Kathy’s fighting served as an occasion to have pri-                    probably was less likely to leave conversations with the
vate time with the mother. Quite likely, time with the                      husband or visiting friend even when Kathy was fight-
80                                              Applied Behavior Analysis

ing. We decided to begin directly with a simple inter-         Each condition might be presented for one to several
vention to test this hypothesis.                               10-minute periods. Plotting data separately for each
   The intervention consisted of providing positive re-        condition often shows that one of the conditions is as-
inforcement (time with the mother) for cooperative             sociated with changes in self-injury and others are not.
play and time out from reinforcement (a period of time         More often than not escape from task demands seems
when opportunities for reinforcement were removed)             to negatively reinforce self-injury. That is, the rate of
for Kathy for fighting. When the girls came home from           self-injury is much higher when the experimenter ends
school/day care, Kathy was told she and the mother             the task as the person engages in self-injury. Once this
could have some play time together if she and her sis-         is demonstrated, one can make escape from task de-
ter played cooperatively for 30 minutes. (Time alone           mands contingent on noninjurious behavior rather
also was provided afterwards with the sister.) Briefly,         than injurious behavior. Escape reinforces positive be-
after the time elapsed without fighting, the mother ef-         havior, and in this way self-injury is no longer rein-
fusively praised the girls and then played with Kathy          forced and can be eliminated.
in her room. If Kathy had a tantrum, she was sent to              Functional analysis represents a significant contribu-
her room for 10 minutes and the mother did not re-             tion of applied behavior analysis. The analysis can sug-
main in the room with her. Requiring longer periods of         gest specific antecedent conditions that promote or
cooperative play to earn time with the mother and              give rise to the behavior as well as identify the conse-
adding father and mother praise for cooperative play           quences maintaining behavior. Scores of demonstra-
essentially eliminated all fighting within the first five         tions have shown how functional analysis can be used
days of the program. The functional analysis was help-         to identify controlling influences and then move to an
ful in conveying the many factors associated with              effective intervention (see Sturmey, 1996). Conse-
fighting and suggesting what might be used to increase          quently, a main benefit of functional analysis is in the
cooperative play.                                              treatment gains that have been achieved in many appli-
   In this simple example, the initial assessment sug-         cations of reinforcement, punishment, and extinction.
gested a pattern of factors related to the behavior. The          Functional analysis is not merely a method of assess-
pattern suggested a hypothesis, and this led directly to       ment and intervening but also a way of thinking about
an intervention. In research, there is a separate step of      behavior. The way of thinking alerts us to the impor-
testing the hypotheses experimentally before moving            tance of considering a range of antecedents and conse-
into the intervention. Usually, the tests are conducted        quences that may influence behavior. Also, the method
in controlled laboratory conditions. The conditions            provides a way of testing hypotheses to help the indi-
are sometimes referred to as analogue testing because          vidual client. What in fact is controlling behavior, and
the behavior and events associated with it are evalu-          how can this be translated into effective treatment?
ated in a contrived situation that is only roughly anal-       Functional analysis provides a means for answering
ogous to conditions in everyday life. Yet, if the              these questions.
laboratory conditions can identify and isolate possible           Functional analysis also provides a methodology
influences (antecedents and consequences), these               for addressing important complexities of behavior.
conditions are likely to exert similar effects in every-       The first of these is that two (or more) individuals
day life.                                                      may be performing identical behaviors (e.g., getting
   Several studies have evaluated self-injurious behav-        into fights at school on the playground, coming late to
ior among children and adults diagnosed with autistic          work or to class, arguing with one’s boyfriend or girl-
disorder. A challenge has been eliminating such behav-         friend), but for quite different reasons. Moreover, a
ior. Functional analyses have evaluated several possible       given child may engage in two or more quite different
controlling factors. Three possibilities have been evalu-      behaviors that in some way serve the same purpose.
ated frequently, including (1) social attention provided       For example, a child may have a tantrum at the dinner
for self-injurious behavior (i.e., positive reinforce-         table every night and also get into trouble at school
ment), (2) escape from the situation to reduce de-             and be placed on detention. These are quite different
mands from others (i.e., negative reinforcement), or           behaviors; they bear no obvious resemblance, and
(3) the stimulation resulting from the behavior itself         they occur in different settings. It is possible that they
(i.e., reinforcement from tactile stimulation). Assess-        serve a similar function, which might be, for example,
ment is conducted for brief periods by an experimenter         that both bring the mother and father together to dis-
who presents these conditions in alternating order.            cipline the child.
                                                Applied Behavior Analysis                                            81
   Conducting a functional analysis is not always feasi-       behavior change. The plan to demonstrate the cause
ble. Also, controlling factors may not be obvious or evi-      of behavior change is referred to as the experimental
dent in the day-to-day life of an individual if, for           design. The purpose of the experimental design is to
example, the consequences are intermittent or the be-          identify the variables that influence, control, or are re-
havior is reinforced by its own performance (e.g., the         sponsible for behavior change. In applied behavior
stimulation it provides). Detailed analyses and extended       analysis, this is referred to as the demonstration of a
observations may not be feasible, either because the re-       functional relation between the target behavior and
sources for observation are limited or because of the ur-      the intervention. A functional relation is demon-
gency to intervene (e.g., to stop a child’s fighting).          strated when altering the experimental condition or
   Many of the techniques based on reinforcement,              contingency systematically changes behavior. Behav-
punishment, and extinction, and other contingency              ior is shown to be a function of the environmental
manipulations have proven to be enormously effective           events that produced change.
in situations in which functional analyses have not               Different experimental designs can be used to show
been done. This is useful to know especially because           that the intervention, rather than extraneous events, was
systematic but simple interventions are often surpris-         responsible for behavior change. The designs are re-
ingly effective if they are carried out systematically.        ferred to as single-case experimental designs. These de-
Even so, functional analysis has provided a powerful           signs are true experiments, which means that they
tool to identify the current factors in the environment        represent a strong basis for drawing causal inferences.
that control behavior and to move to an intervention           Although such designs can be used with large groups of
phase in which these factors are altered to promote            individuals, their unique characteristic is that they can
prosocial and adaptive behavior.                               be used with individual cases (e.g., one patient or stu-
                                                               dent). In single-case research, inferences are usually
                                                               made about the effects of the intervention by comparing
               D. Evaluation and                               different conditions presented to one or a few individu-
              Single-Case Designs                              als over time.
   Assessment of the target behavior(s) is quite valuable         There are a number of basic requirements that sin-
for identifying the scope of the problem, and possible         gle-case experimental designs share and that are funda-
factors contributing to the problem as well as for evalu-      mental to understanding how conclusions are drawn.
ating whether there has been a change over the course          The most fundamental design characteristic is the re-
of the intervention. Assessment may reveal that a              liance on continuous assessment, that is, repeated ob-
change has occurred, but it does not show what caused          servations of performance over time. The client’s
the change. Proponents of applied behavior analysis are        performance is observed on several occasions, usually
extremely interested in determining the causes of be-          before the intervention is applied and continuously
havior change. The short-term benefits of interventions         over the period while the intervention is in effect. Typ-
to the individual client and the long-term benefits of          ically, observations are conducted on a daily basis or at
interventions for society at large will derive from un-        least on multiple occasions each week. These observa-
derstanding what produces change, the bases or rea-            tions allow the investigator to examine the pattern and
sons for the change, and the factors that one might            stability of performance. The pretreatment information
alter to optimize the change. The prior comments on            over an extended period provides a picture of what per-
functional analysis convey explicitly how assessment           formance is like without the intervention. When the
can be used to identify factors that control behavior          intervention eventually is implemented, the observa-
and then how this information is used to develop effec-        tions are continued and the investigator can examine
tive interventions. Evaluating the basis or reason for         whether behavior changes coincide with the interven-
change extends beyond functional analysis. Whether or          tion. There are a number of experimental designs in
not one conducts a functional analysis, there is an in-        which causal relations can be drawn between the inter-
terest in evaluating whether the intervention was re-          vention and behavior. An example of one design is pro-
sponsible for change.                                          vided here to illustrate the approach.
   The cause of behavior change can be demonstrated               The multiple-baseline design demonstrates the effect
in different ways. The clinical investigator who de-           of an intervention by showing that behavior change ac-
signs the intervention usually plans the situation to          companies introduction of the intervention at different
identify whether the intervention was responsible for          points in time. The key feature of the design is evalua-
82                                                Applied Behavior Analysis

tion of change across different baselines. Ideally,              intervention is likely to be responsible for change.
change occurs when the intervention is introduced in             Among approaches to treatment, the collection of on-
sequence to each of the baselines. Multiple-baseline de-         going data during the intervention, the use of this in-
signs vary depending on whether the baselines refer to           formation to make changes in treatment, and the
different behaviors, different individuals, different situ-      experimental evaluation of intervention effects are
ations, or time periods. For example, in the multiple-           rather unique.
baseline design across behaviors, a single individual or            Use of the information collected during treatment
group of individuals is observed. Data are collected on          and as part of an evaluation of that treatment warrants
two or more behaviors, each of which eventually is to            additional comment. Continuous assessment, unique
be altered. The behaviors are observed daily or at least         to single-case designs, provides the investigator or cli-
on several occasions each week. After each of the base-          nician with feedback regarding how well the interven-
lines shows a stable pattern, the intervention is applied        tion is working. This is perhaps the main applied
to only one of the behaviors. Baseline conditions re-            advantage of single-case designs, namely, the ability to
main in effect for the other behaviors. The initial be-          see how or whether treatment is working and making
havior to which treatment is applied is expected to              changes as needed while the treatment or intervention
change, while other behaviors remain at pretreatment             is still in effect. Indeed, the success of interventions
levels. When the treated behavior stabilizes, the inter-         studied in applied behavior analysis not only stems
vention is applied to the second behavior. Treatment             from powerful procedures (e.g., reinforcement), but
continues for the first two behaviors, while baseline             also from being able to identify weak treatment effects
continues for all other behaviors. Eventually, each be-          early and rectifying them. Clearly, the main advantage
havior is exposed to treatment but at different points in        of the designs is that they allow careful investigation
time. A causal relation between the intervention and             of an individual client. Thus, both the target focus
behavior is clearly demonstrated if each behavior                and the interventions can be individualized to the cir-
changes only when the intervention is introduced and             cumstances and situation of the individual.
not before. (Examples of multiple-baseline designs are
presented later in the chapter.)
   Multiple-baseline designs are user friendly in clinical                    IV. EMPIRICAL STUDIES
and other applications because the intervention is ap-
plied in a sequential fashion. The investigator may wish            Many different techniques can be derived from oper-
to change many different behaviors of an individual, a           ant conditioning principles. It is not possible to review
behavior of an individual across many different situa-           the evidence for each technique variation because of
tions, or the behavior of many different individuals.            the scope of applications and weight of the evidence
Rather than introducing the intervention to all of these         (see Further Reading). Examples are provided to illus-
at once, the program initially focuses on only one be-           trate the approach, selected techniques, and the type of
havior, situation, or individual. If the intervention is ef-     evidence used to demonstrate effectiveness.
fective, then it can be extended to all of the other
behaviors for which change is desired. As importantly,
                                                                                 A. Reinforcement
if the intervention is ineffective or insufficiently effec-
tive to achieve important changes, it can be altered or             Techniques based on positive reinforcement serve
improved before it is extended.                                  as the core interventions of applied behavior analysis.
   Implementing a single-case experimental design                If the goal is to develop positive, adaptive behavior,
during an intervention program is not always possible            reinforcement is obviously suitable because reinforce-
because of constraints of the situation. There are, how-         ment operates to increase the behavior. Even if the
ever, many designs, some of which are more feasible              goal is to reduce or eliminate behavior (e.g., stealing,
and flexible than others. Whether or not a formal de-             aggression, gambling), positive reinforcement usually
sign or some approximation is used to evaluate the               plays a central goal. Developing positive, prosocial be-
causal influence of the intervention, in applied behav-           havior is effective as a way of eliminating or reducing
ior analysis some evaluation is conducted. It is essen-          maladaptive behavior. The positive prosocial behav-
tial to see if behavior changes occur with treatment, if         iors that are reinforced are often opposite to or incom-
these changes are important (i.e., have a palpable im-           patible with the undesired behavior, so that increasing
pact on the problem), and, to the extent possible, if the        such behaviors (e.g., positive marital communication)
                                                Applied Behavior Analysis                                           83
can be quite effective as a way of reducing undesirable        cocaine and marijuana use was accomplished by uri-
behavior (e.g., arguing).                                      nalyses that detected use within the previous 72 hours.
   Intervention programs based on positive reinforce-          Assessment was conducted four times a week to pro-
ment have used attention, praise, feedback, and activi-        vide opportunities for earning tokens. Points were pro-
ties in which people like to engage as the reinforcing         vided when the assessment indicated no sign of cocaine
consequences for behavior. Often, multiple reinforcers         use. Bonus points were given for extended periods
are incorporated into a single program, referred to as a       without a sign of drug use. Points could be exchanged
token economy. In a token economy, tokens function in          for small amounts of money or goods and services, in-
the same way that money does in national economies.            cluding movie tickets, sporting events, ski-lift tickets,
Tokens are earned and then used to purchase backup             and dinner certificates. The purpose of using these
reinforcers, such as food and other consumables, activ-        backup rewards was not only to imbue the points with
ities, and privileges. The basic requirements of a token       value but also to involve the individuals in prosocial
economy include specification of (1) the target behav-          activities and, it was hoped, to develop a reinforcing,
iors, (2) the number of tokens that can be earned for          drug-free lifestyle. After 12 weeks of the program, a
performance of the behaviors, (3) the backup rein-             maintenance phase was initiated to reduce the fre-
forcers that are available, and (4) the number of tokens       quency of the checks on drug use. In the final phase,
the backup reinforcers cost.                                   marijuana use was added to the program. To earn to-
   As an illustration, token economies have been used          kens, the tests had to show that the individual did not
extensively in psychiatric hospitals. In one of the most       use cocaine or marijuana.
carefully evaluated programs, patients received tokens            Figure 1 plots the number of negative urine speci-
(colored plastic strips) for such behaviors as attending       mens (no sign of drug use) in a cumulative graph for
activities on the ward, group meetings, and therapy ses-       each person. The figure shows that when reinforcement
sions; grooming, making one’s bed, showering, and en-          was given for cocaine abstinence, tests for cocaine use
gaging in appropriate mealtime behaviors; and socially         were negative. Marijuana continued to be used until
interacting. Tokens could be exchanged for a variety of        the final phase, in which abstinence from both cocaine
backup events such as purchasing cosmetics, candy, cig-        and marijuana was reinforced. The sequence of inter-
arettes, and clothing; renting chairs or bedside stands        ventions across two individuals seen at the clinic and
for one’s room; ordering items from a mail-order cata-         across two drugs follows the criteria of a multiple-base-
log; using a piano, record player, or radio; spending          line design. The pattern suggests that the token rein-
time in a lounge; watching television; having a private        forcement program was responsible for the change.
room, and sleeping late. As patients improved in the           Followup assessment, including reports from others
ward, they advanced to higher levels within the pro-           (girlfriend, roommate) and from the clients them-
gram, in which more reinforcers were available and             selves, indicated no use of cocaine but some occasional
higher criteria were set for performance. Patients could       use of marijuana.
“buy” themselves off the system by doing well, and each           The adaptability of the token economy can be illus-
carried a “credit card” that allowed free access to all of     trated by moving from the focus on one or two individ-
the available reinforcers as long as personal perform-         uals, in the previous example, to a larger-scale
ance was up to standards. The program was very suc-            application in business and industry. For example, in
cessful in reducing bizarre behaviors, improving social        one study the focus was on worker safety. The study
interaction and communication skills, and developing           was conducted at two open-pit mines, one in Wyoming
participation in activities. The gains were reflected in        and the other in Arizona. Uranium was extracted and
the number of patients discharged and in their adjust-         processed at one of the mines; coal was extracted and
ment in the community from one and a half to five years         processed at the other. The two mines used similar
after the program ended.                                       equipment (trucks, bulldozers) and procedures (strip
   Token reinforcement can be used with a group or             mining, crushing, storing materials). The goals of the
with one or two individuals. For example, a token sys-         program were to decrease job-related injuries, days lost
tem was used to treat patients referred for drug addic-        from work due to such injuries, and costs (due to med-
tion. Two adult males (Phil, age 28; Mike, age 35) were        ical care, insurance, and equipment damage) among
seen separately for cocaine addiction. Both also used          employees in each mine.
marijuana, which apparently is the case for 40 to 50              An incentive in the form of tokens (trading stamps)
percent of persons addicted to cocaine. Assessment of          was provided at the end of each month to workers who
84                                               Applied Behavior Analysis




                   FIGURE 1 Cumulative number of negative cocaine and marijuana urinalysis results
                   obtained with Phil and Mike during three phases of treatment as a function of tests
                   conducted throughout treatment. Cocaine and marijuana test results are presented by
                   closed and open symbols, respectively. Steep slopes in the cumulative record indicate
                   change; horizontal lines indicate no change. [Budney, A. J., Higgins, S. T., Delaney, D.
                   D., Kent, L., & Bickel, W. K. (1991). Contingent reinforcement of abstinence with in-
                   dividuals abusing cocaine and marijuana. Journal of Applied Behavior Analysis, 24,
                   657–665.]


had not been injured or had not required medical care             Bonus stamps were available to workers whose sugges-
because of an accident. Trading stamps were also given            tions for improving safety in the facility were adopted.
to all members of a group that worked under a particu-            Trading stamps could also be lost (response cost) for
lar supervisor if no one in the group had been injured.           missing work due to injury or for causing an accident.
                                                Applied Behavior Analysis                                           85
The trading stamps could be exchanged at a nearby re-          who administer the program often show marked im-
demption center that carried hundreds of items, such           provements in the target behaviors and hence share in
as small appliances, barbecue grills, spice racks, and         the benefits of the intervention.
clocks. The program was introduced to each mine in a
multiple-baseline design and integrated with the mine’s
                                                                                 B. Punishment
routine practices for several years. Figure 2 shows a
marked reduction in the number of accidents among                 The types of aversive events used and how they are
workers (upper panel) as well as a reduction in mone-          applied in behavioral programs differ greatly from
tary costs to the company (lower panel).                       punishment practices in everyday life. In behavioral
   Token economies have been used with a variety of            interventions, rarely is punishment used by itself.
populations, including persons with mental retarda-            Rather, punishment is part of a larger program based
tion, prisoners, geriatric or nursing home residents,          on positive reinforcement that develops adaptive be-
persons who abuse alcohol and drugs, outpatient chil-          havior. There are many reasons for emphasizing posi-
dren and adults, and members of the armed forces (e.g.,        tive reinforcement, even when the goal is to suppress
in basic training). Similarly, the various settings in         or eliminate some undesirable behavior. Perhaps
which token economies have been applied include the            most significantly, deviant behavior often can be
home, schools, institutions, hospitals, day-care centers,      eliminated effectively with little or no punishment.
nursing homes, and business and industry. Probably             There are a variety of ways of delivering reinforce-
the setting most often used is in the home where par-          ment to support behaviors incompatible with the de-
ents use points, marks on a chart, or stars on a tempo-        viant behavior that work quite well to eliminate
rary basis to foster behaviors such as completing              undesired responses.
chores, homework, and taking care of pets. Simple re-             Punishment is also deemphasized because it does
inforcement programs are an excellent way to manage            not train an individual regarding what to do. Merely
behavior, to move away from nagging, reprimands, and           suppressing behavior and training the individual in
punishment in general. Usually in such applications to-        what not to do will not necessarily foster the desired or
kens are not “needed.” That is, the behavior could be          appropriate behaviors. Indeed, without an effort to de-
changed with prompts, praise, and shaping. Yet, the to-        velop behaviors through positive reinforcement, pun-
kens provide a useful way to structure and prompt par-         ishment may not be very effective as a way of changing
ent behavior so that the consequences are applied              behavior in the long term. The suppressed responses
systematically.                                                are likely to return unless some other behaviors have
   The discussion of reinforcement has emphasized              replaced them.
token reinforcement because this is an adaptable sys-             Punishment often is associated with undesirable side
tem for integrating several behaviors and reinforcers.         effects, such as emotional reactions (crying), escape
In many applications, reinforcers such as praise and           from and avoidance of situations (e.g., staying away
privileges have been extremely effective in changing           from a punitive parent), and aggression (e.g., hitting
the behavior of children, adolescents, and adults in the       others). None of these is necessary for behavior to
diverse settings, mentioned previously. Apart from the         change. Punishment can foster undesirable associa-
diversity of reinforcers (e.g., praise, activities), pro-      tions with regard to various agents (parents, teachers),
grams can vary on whether the reinforcers are deliv-           situations (home, school), and behaviors (doing home-
ered on the basis of how the individual or group               work). An important objective in child rearing, educa-
performs and who administers the program (e.g., par-           tion, and socialization in general is to develop positive
ents, teachers, peers). Indeed, the range of options ac-       attitudes and responses toward these agents, situations,
counts for the broad applicability of reinforcement            and behaviors; their frequent association with punish-
procedures. For example, in school settings, peers             ment may be counterproductive. For example, scream-
(older classmates at the school) often are involved in         ing at a child to practice a musical instrument is not
administering reinforcers to others for academic be-           likely to develop a love of music. For all of these rea-
havior (e.g., completing assignments correctly) or so-         sons, programs emphasize positive reinforcement.
cial interaction (e.g., appropriate initiations of contact        Proponents of behavioral techniques are extremely
with others). Peer-administered reinforcement pro-             concerned with abuse and misuse of punishment.
grams have been effective in many applications. Inter-         Such abuse and misuse have been shown to foster se-
estingly, the individual whose behavior is reinforced          rious problems in children and adolescents. For ex-
changes, as would be expected. In addition, the peers          ample, use of harsh punishment in the home is related
86                                              Applied Behavior Analysis




                    FIGURE 2 Yearly number of days lost from work per million person hours
                    worked, resulting from work-related injuries (upper figure) and yearly cost, ad-
                    justed for hours worked and inflation, resulting from accidents and injuries (lower
                    figure). [Fox, D. K., Hopkins, B. L., & Anger, W. K. (1987). The long-term effects of
                    a token economy on safety performance in open-pit mining. Journal of Applied Be-
                    havior Analysis, 20, 215–224.]

to later deviant and delinquent behavior of the child.             In applied behavior analysis, when punishment is
Both physical and verbal punishment (reprimands)                used, it usually consists of withdrawing positive events.
can increase the very behaviors (noncompliance, ag-             The most commonly used form is time out from rein-
gression) that parents, teachers, and others wish to            forcement, which refers to the removal of a positive re-
suppress.                                                       inforcer for a brief period of time (e.g., a few minutes).
                                                  Applied Behavior Analysis                                            87
During the time-out interval, the client does not have           change. Conditions to maximize the impact of response
access to the positive reinforcers that are normally             cost include immediacy and schedule of the fine and re-
available in the setting. For example, a child may be            inforcement for alternate behavior, to mention a few.) In
isolated from others in class for five minutes. During            applied behavior analysis, fines usually consist of loss of
that time, he or she will not have access to peer interac-       tokens (chips, stars, points) that are provided for posi-
tion, activities, privileges, and other reinforcers that are     tive behavior in a token economy.
usually available.                                                  As an example, response cost was used to reduce ag-
   A variety of time-out procedures have been used ef-           gressive and disruptive behavior in the classroom of
fectively. In many variations, the client is physically          four preschool boys (ages 3–5). The children engaged
isolated or excluded in some way from the situation.             in such behaviors as throwing things, damaging other
The client may be sent to a time-out room or booth, a            children’s materials, hitting, and screaming. Response
special place that is partitioned off from others (in the        cost consisted of providing a child with five laminated
classroom, at home, or in an institution). In other vari-        smiley faces attached to a larger sheet. The chart was
ations, the client is not removed at all. For example, in        labeled Good Behavior Chart and posted in the class-
one variation, developed initially in a special education        room for all to see. Each time the child engaged in one
classroom, children received praise and smiles (social           aggressive behavior, a smiley face was taken away. The
reinforcement) from the teacher for performing their             teacher stated the reason for the loss of the smiley face
work. Each child in the class was given a ribbon to              and provided a reprimand. If the child retained at least
wear around his neck. The ribbon signified to the child           one smiley face at the end of the 40-minute period, he
and the teacher that the child could receive social and,         could purchase special rewards (e.g., being the
occasionally, food reinforcers that were administered            teacher’s helper, access to a favorite toy). Consistent
while the children worked. When any disruptive be-               performance over at least four or five days was rein-
havior was performed, time out was used. It consisted            forced with additional incentives (a special grab bag).
of removing the child’s ribbon for three minutes. With-          Response cost was introduced in a multiple-baseline
out the ribbon, the child could not receive any of the           design across children. As is evident in Figure 3, ag-
reinforcers normally administered (e.g., attention from          gressive behavior changed markedly as the interven-
the teacher). This time-out procedure effectively re-            tion was introduced.
duced disruptive classroom behavior.                                Many other punishment procedures are available
   In general, time out provides an excellent alternative        such as the contingent use of effort (tasks, chores),
to many of the forms of punishment used in everyday              loss of privileges, and requiring individuals to rectify
life, such as reprimands and corporal punishment. Very           or correct the situation their behavior may have al-
brief time out, for several seconds or a few minutes, has        tered. As noted previously, the primary use of punish-
been effective. Longer periods of time out (e.g., 10, 20         ment in applied behavior analysis is as a supplement
minutes) do not necessarily increase the effectiveness           to a positive reinforcement program. Punishment by
of the procedure. Indeed, brief and contingent time out          itself raises all sorts of objections and concerns and
is quite effective, especially if many reinforcers are           often is not very effective. However, mild punishment
available in the setting and these are administered for          (e.g., brief time out, response cost) when supple-
positive behavior.                                               mented with positive reinforcement for prosocial
   An another punishment procedure is referred to as re-         behavior can be extremely effective. Although rein-
sponse cost and also consists of loss of a positive rein-        forcement by itself can often be used to eliminate un-
forcer. Response cost entails a penalty of some sort             desirable behaviors, the addition of very mild
contingent on behavior. With response cost, there is no          punishment often augments the effectiveness of the
time period during which positive events are unavail-            reinforcement program.
able, as is the case with time out. Typically, response             A difficulty in using punishment at all is that peo-
cost consists of a fine. Examples of response cost in             ple familiar with punishment in every day life may
everyday experience include fines for traffic violations           implement aversive events in ways that do not en-
or overdue books, fees for late filing of income tax or for       hance efficacy or that promote problems (e.g.,
registering for classes beyond the due date, and charges         screaming, hitting, trying to evoke emotional re-
for checks that “bounce.” (Although these examples il-           sponses). Shouting, hitting, screaming, making
lustrate response cost, the examples do not reflect pun-          threats, or shaking someone, not all that rare in the
ishment administered in ways that maximize behavior              home and classroom and indeed in parent–child and
88                                                  Applied Behavior Analysis

                                                                   monitored carefully, may drift into one of these other
                                                                   punishment procedures.

                                                                                       C. Extinction
                                                                      Many maladaptive behaviors are maintained by con-
                                                                   sequences that follow from them. For example, temper
                                                                   tantrums or interrupting others during conversations
                                                                   are often unwittingly reinforced by the attention they
                                                                   receive. When there is interest in reducing behavior,
                                                                   extinction can be used by eliminating the connection
                                                                   between the behavior and the consequences that fol-
                                                                   low. Extinction refers to withholding reinforcement
                                                                   from a previously reinforced response. A response
                                                                   undergoing extinction eventually decreases in fre-
                                                                   quency until it returns to its prereinforcement level
                                                                   or is eliminated.
                                                                      Extinction has been successfully applied to diverse
                                                                   problems. As an illustration, extinction was used to re-
                                                                   duce awakening in the middle of the night among in-
                                                                   fants. Nighttime waking, exhibited by 20 percent to 50
                                                                   percent of infants often is noted as a significant problem
                                                                   for parents. Parents may play a role in sustaining night
                                                                   waking by attending to the infant in ways that reinforce
                                                                   the behavior. In this program, parents with infants (8 to
                                                                   20 months old) participated in an extinction-based pro-
                                                                   gram to decrease nighttime awakening. Waking up dur-
                                                                   ing the night was defined as a sustained noise (more
                                                                   than one minute) of the infant between onset of sleep
                                                                   and an agreed-upon waking time (such as 6:00 A.M.).
                                                                   Over the course of the project, several assessment pro-
                                                                   cedures were used, including parent recording of sleep
                                                                   periods, telephone calls to the parents to check on
                                                                   these reports, and a voice-activated recording device
                                                                   near the child’s bed. After baseline observations, par-
                                                                   ents were instructed to modify the way in which they
                                                                   attended to night wakings. Specifically, parents were
                                                                   told to ignore night wakings. If the parent had a con-
                                                                   cern about the health or safety of the child, the parent
                                                                   was instructed to enter the room, check the child qui-
                                                                   etly and in silence with a minimum of light, and to
FIGURE 3 Rate of aggressive behavior during baseline and
                                                                   leave immediately if there was no problem.
treatment conditions across subjects. [Reynolds, L. K., &
Kelley, M. L. (1997). The efficacy of a response cost treatment
                                                                      The program was evaluated in a multiple-baseline de-
package for managing aggressive behavior in preschoolers.          sign across seven infants. Figure 4 shows the frequency
Behavior Modification, 21, 216–230.]                                of night wakings each week for the children during the
                                                                   baseline and intervention periods. As is evident in the
                                                                   figure, the frequency decreased during the intervention
                                                                   period. Followup consisted of assessment approximately
spouse–spouse interactions, are not events used in ap-             three months and then two years later, which showed
plied behavior analysis. A danger of implementing                  maintenance of the changes. The figure is instructive for
punishment is that well-designed programs (e.g., two               other reasons. Two weaknesses of extinction programs
minutes of time out contingent on behavior), if not                were evident. First, extinction effects tend to be gradual.
                                                    Applied Behavior Analysis                                                 89




FIGURE 4 Frequency of night wakings per week for seven infants treated with extinction. The program was evaluated in a mul-
tiple-baseline design across infants. Followup 1 and 2 represent evaluation at three months and two years after the initial inter-
vention program, respectively. The solid, large dots denote nights in which the infant was ill. [France, K. G., & Hudson, S. M.
(1990). Behavior management of infant sleep disturbance. Journal of Applied Behavior Analysis, 23, 91–98.]



Second, during extinction the behavior may momentar-                in ignoring behavior and discriminating when behavior
ily recover (i.e., emerge for one or two occasions) even            does and does not warrant attention. In any case, the
though it has not been reinforced, a phenomenon re-                 demonstration is clear in showing that extinction gen-
ferred to as spontaneous recovery. Figure 4 shows both              erally was quite effective in decreasing night waking
the gradual nature of extinction and repeated instances             among infants.
of spontaneous recovery during the intervention and fol-                Typically, extinction is used in conjunction with pos-
lowup phases. The prospect of accidental reinforcement              itive reinforcement. The main reason is that the effec-
(e.g., attention to the behavior) during these periods re-          tiveness of extinction is enhanced tremendously when
quires special caution on the part of parents.                      it is combined with positive reinforcement for behavior
   A related issue pertains to Child 3 (in Figure 4), who           incompatible with the response to be extinguished.
did not profit from the program. Parents reported diffi-              Also, the gradual effects of extinction, the emergence of
culty in distinguishing the usual night wakings from                the undesired behavior (spontaneous recovery), and
those associated with illness of their child. Additional            untoward side effects are mitigated when extinction is
data revealed that these parents attended relatively fre-           combined with positive reinforcement. A limitation of
quently to nonillness awakenings during the interven-               extinction is that it is not always easy (without func-
tion but improved during the first followup phase. The               tional analysis) to identify what reinforcers are main-
parents cannot be faulted. The pattern of behavior and              taining behavior, especially if the reinforcers are quite
eventual improvement draw attention to the difficulty                intermittent and hence not evident each time the be-
90                                              Applied Behavior Analysis

havior occurs. As with the use of punishment, extinc-          analysis is possible, current causes of behavior are
tion by itself does not teach the positive behaviors to be     demonstrated and the information is used to develop
developed and may be associated with undesirable side          an effective intervention.
effects. For all of these reasons, extinction usually is
combined with positive reinforcement for appropriate
or prosocial behavior.                                                         V. APPLICATIONS
   Many reports have shown the successful application
of extinction alone or in conjunction with other proce-           Perhaps one of the most striking features of applied
dures (particularly reinforcement). Hypochondriacal            behavior analysis is the scope of applications. Table 6
complaints, vomiting, obsessive comments, compul-              samples some of the applications to illustrate the
sive rituals, and excessive conversation in the class-         breadth of the approach. Interventions have been car-
room are among the diverse problems that have been             ried out in diverse settings such as the home, at school,
treated with extinction and reinforcement. Such appli-         institutions (hospitals, rehabilitation centers, nursing
cations are particularly noteworthy because they reveal        homes), business and industry, and the community. In-
that a number of maladaptive behaviors may be main-            deed, it is safe to say no other psychological interven-
tained at least in part by their social consequences.          tion or approach has been applied as widely to human
                                                               behavior.
                                                                  The focus of behavior analysis is often on the indi-
             D. General Comments                               vidual. Indeed, this is strongly suggested by reliance on
   Interventions based on positive reinforcement, pun-         single-case experimental designs. Already mentioned
ishment, and extinction, merely sampled in this contri-        was the fact that these designs can be applied to groups
bution, have been quite effective among diverse clients,       or to interventions implemented on a large scale. For
settings, and target behaviors. The effectiveness can be       example, one program (Behavior Analysis Follow
traced to two features of applied behavior analysis.           Through Project) was implemented in elementary
First, the principles of operant conditioning reflect po-       school grades over a period of several years and grade
tent influences on behavior. Positive reinforcement, for        levels. The program included more than 7,000 children
example, has a strong influence on behavior and has             in approximately 300 classrooms (from kindergarten
been demonstrated across multiple species and circum-          through third grade) in 15 cities throughout the United
stances. Experimental and applied research have iden-          States. The program relied heavily on token reinforce-
tified many of the conditions on which effective               ment to promote academic performance and several
applications depend (e.g., immediacy and schedule of           other components, such as instructing children in
delivering consequences). Consequently, there are clear        small groups within the class, using academic curricula
guidelines on how to apply many of the interventions           that permitted evaluation of student progress, specify-
effectively.                                                   ing performance criteria for teachers and students, and
   Second, the assessment and evaluation of applied be-        providing special training and feedback to teachers re-
havior analysis contributes directly to program effec-         garding their performance and the progress of their stu-
tiveness. Ongoing measurement is made of client                dents. The gains in academic performance of students
performance, whether the problem is changing, and to           who participated in the program were markedly greater
what extent. This means that during the intervention,          than were the gains of students in traditional class-
weak, mediocre, or no effects of treatment can be iden-        rooms. Moreover, those gains were still evident two
tified and remedied. There are scores of applications in        years after the program had been terminated and the
which programs produced mediocre effects. Alterations          children in the program had entered classrooms where
or additions were made in the program that then                token reinforcement was not in effect.
achieved the desired changes. Other approaches to                 In large-scale programs, as for example with all people
treatment usually do not provide ongoing assessment            who work in a corporation, who live in a particular city
and hence do not have the benefit of this immediate             or neighborhood, or who live in a dormitory, it may not
feedback to help decision making in treatment. Re-             be feasible to provide consequences (e.g., positive rein-
lated, functional analysis is a special way in which as-       forcers) based on the performance of each individual.
sessment, evaluation, and intervention are interrelated.       Difficulties in monitoring individual performance or in-
With functional analysis, the factors that are maintain-       sufficient resources to administer reinforcers to each
ing an undesired behavior or not supporting a desired          individual raise special obstacles. Yet, in such circum-
behavior can be precisely identified. When functional           stances, group contingencies may play an especially
                                                   Applied Behavior Analysis                                                   91
                                                         TABLE 6
                             Sample of the Scope of Applications of Applied Behavior Analysis

Context/setting                                               Interventions have been effective in …

Therapy/treatment settings        Treating a broad range of psychological problems and psychiatric disorders including anxiety
                                    (e.g., fears, obsessive compulsive disorders, panic attacks), depression, substance use and
                                    abuse (e.g., drug, alcohol, cigarettes), conduct problems, hyperactivity, autism, and eating
                                    disorders.
Education                         Improving academic performance, studying, achievement, grades, classroom deportment,
                                    creative writing, participation in activities, as relevant to elementary, middle, and high
                                    school students; mastery of the subject matter at all levels including college students. Many
                                    programs in school settings have focused on behaviors beyond the usual domain of educa-
                                    tion because schools provide a useful place to deliver the interventions. Thus, behavioral
                                    programs have been applied to reduce or prevent cigarette smoking, alcohol and drug use,
                                    and unprotected sex among adolescents.
Medicine and health               Teaching individuals to detect early signs of disease (e.g., cancer checks through self-
                                    examination), protect against sexually transmitted diseases, reduce pain associated with in-
                                    vasive medical procedures (e.g., lumbar taps) or postoperative recovery, and adhere to
                                    medical regimens (e.g., for cancer, diabetes).
Business and industry             Teaching workers to engage in practices that reduce accidents (e.g., when using equipment),
                                    improve health or overcome problems that compete with health and work (e.g., alcohol
                                    use, cigarette smoking). Helping individuals to obtain jobs (e.g., how to seek jobs, inter-
                                    view skills), improve on-the-job performance, reduce absenteeism, tardiness, improve em-
                                    ployee customer interactions, and reduce shoplifting among customers.
Sports and athletics              Improving coaching practices, performance of athletes (e.g., in football, gymnastics, tennis,
                                    swimming, and track) and stress management among athletes.
Everyday life                     Training parents to interact with their children for parents who are in special situations (e.g.,
                                    handicapped child), for children who are in special situations (e.g., abused, neglected chil-
                                    dren) and parents without special difficulties or obstacles; training children to engage in
                                    safe behaviors (e.g., use of seat belts, crossing streets) or ward off dangerous situations
                                    (e.g., responding to would-be abductors). Training the elderly in nursing homes to increase
                                    physical activity and engage is more social interactions with others. Training individuals to
                                    engage in safe-driving practices, conserve energy in homes, and recycle wastes.




important role. For example, in some business or-                  mands of implementing the techniques effectively and
ganizations, special incentives are provided if a group            the importance of ensuring that the behaviors are
(e.g., 90 percent of all employees) engages in a behavior          maintained and transfer to multiple settings or condi-
of interest (e.g., donates to a charity, participates in an        tions beyond those in which the intervention program
exercise program designed to improve health). In these             was in effect.
situations, the interest in developing a particular behav-
ior across many people lends itself well to group contin-
                                                                                 A. Implementation and
gencies. The effectiveness of such contingencies is
evaluated by charting the behavior of the group rather
                                                                                 Program Effectiveness
than the performance of one or a few individuals.                    The principles of reinforcement, punishment, and
                                                                   extinction and the techniques derived from those
                                                                   principles are relatively simple. Moreover, the tech-
        VI. ISSUES AND CHALLENGES                                  niques resemble practices used in everyday life, which
                                                                   make the behavior-change programs deceptively sim-
  Although interventions based on operant condition-               ple. For example, parents who are learning behavioral
ing principles have been extremely effective in diverse            techniques for managing their children invariably
applications, many issues and challenges emerge in                 note that these techniques are not new and that they
their application. Two salient issues pertain to the de-           have been using the techniques all along. They often
92                                              Applied Behavior Analysis

assert that their use of reinforcement (praise or al-             A significant challenge is the training of behavior-
lowance) or time out (sending the child to his or her          change agents (e.g., parents, teachers, staff of the institu-
room) has not worked. Parents are usually correct in           tion, peers who carry out the program). Many successful
this assertion. Yet, careful inquiry or direct observation     programs have devoted considerable attention to ensur-
of parent behavior in the home reveals that the proce-         ing that these behavior-change agents are well trained.
dures they have tried are faint approximations of the          Once these change agents have been trained, their be-
ways in which reinforcing and punishing consequences           haviors are often monitored carefully to ensure that the
are used in applied behavior analysis. For example,            contingencies are carried out correctly. Without careful
positive reinforcers need to be contingent on perform-         training and monitoring, the care with which interven-
ance and delivered immediately after behavior and on a         tions are implemented may deteriorate over time. As-
continuous or close to continuous schedule, especially         sessment and monitoring of those who implement the
at the beginning of the program. As important, the tar-        intervention may need to become a permanent part of
get behaviors need to be carefully specified, so that re-       the setting (e.g., school, hospital). For example, large-
inforcement can be applied consistently and the results        scale applications of behavioral programs in schools
can be measured to see whether the program is having           often include assessment and monitoring of teacher and
an impact. Rarely are these conditions in place in the         student behavior to ensure that the techniques are im-
causal applications of incentives or disincentives for         plemented correctly and that children are learning. The
behavior (e.g., at home or at school).                         assessment and supervision practices are central to the
   Interventions usually require consideration of an-          effectiveness of the procedures, hence, their incorpora-
tecedents, behaviors, and consequences and quite spe-          tion as part of the program is critically important. A
cific ways of delivering consequences. In fact, what            major challenge is not just changing client behavior, but
distinguishes behavior modification techniques from             also changing the behavior of those responsible for im-
everyday uses of reward and punishment is how the              plementing the program.
techniques are applied and evaluated. Several condi-
tions influence whether reinforcement, punishment,
and extinction are effective, and hence the interventions
                                                                            B. Response Maintenance
are more than merely providing some consequence for
                                                                            and Transfer of Training
behavior. Once these conditions (e.g., use of prompts,            Interventions discussed in this chapter clearly show
shaping) are faithfully rendered, one may be in a better       that behavior can be changed. Two critical questions
position to say that the procedures have not worked.           are whether the changes will be maintained once the
   Interventions based on the principles of operant con-       special programs are ended and whether the changes
ditioning bring to bear important influences to change          during and after the program will extend to settings,
behavior. Yet, the techniques do not always achieve the        situations, or circumstances that were not included in
desired outcomes. There have been many instances in            the program. These concerns reflect response mainte-
which behavioral programs failed to achieve the desired        nance and transfer of training, respectively. Mainte-
changes. No change may have occurred, or the change            nance of behavior changes might not be expected after
may be too small to make an important difference in the        an intervention program is ended. If the client re-
lives of the clients or those with whom they interact.         sponds to changes in the contingencies of reinforce-
The most common reason for program failures pertains           ment, one might expect changes to be lost after the
to poor, mediocre, and inconsistent implementation of          intervention is terminated. Similarly, if clients make
the contingencies. Interestingly, several studies have         discriminations about the situations in which the inter-
shown that slight modifications in the program when             vention is and is not in effect, one might expect
clients have failed to respond often produce the desired       changes in behavior to be restricted to those situations
behaviors. In some cases, the changes occur from imple-        in which the program was in effect.
menting the program in ways more conducive to pro-                Early in the development of applied behavior analysis,
ducing change (e.g., more immediate reinforcement). In         almost exclusive attention was devoted to changing be-
other cases, the procedures are changed. For example,          havior and indeed seeing whether significant behaviors
defiant and aggressive child behavior in the home or at         of impaired populations (e.g., persons with mental retar-
school may not be altered by simply having parents             dation or psychiatric disorder) could be significantly
praise appropriate child behavior. The undesired behav-        helped by the interventions. As change became demon-
iors may not decrease until mild punishment (time out,         strated in diverse contexts and settings, further attention
response cost) is added to the contingencies.                  was accorded to procedures that can be used during a
                                                        Applied Behavior Analysis                                                  93
program to promote response maintenance and transfer                   text of sexual abuse more generally. In this project,
of training. Currently, there are several procedures that              the investigators trained women to refuse sexual over-
can be implemented during an intervention program                      tures from others, to say no, to leave the situation, to
that help to ensure that the desired behaviors are main-               tell the incident to others, and to use similar behav-
tained and are not restricted to situations, persons, or               iors when inappropriate approach responses were
settings associated with the intervention when it was ini-             made to them. Training was conducted with pairs of
tiated. Table 7 highlights several strategies that are used            women in which they practiced the target behaviors
after behavior has been developed to foster maintenance                (what they would say and do) in a set of hypothetical
and transfer of the changes.                                           situations. Training developed the desired behaviors
   As an illustration, transfer of training was systemati-             using role play, practice, feedback, and praise. Then
cally trained in one program to ensure that the behaviors              tests were provided in a realistic situation in which an
extended to the situations of interest after training. In              unknown male made approach responses. The results
this program, adult mentally retarded women were                       revealed that the behaviors developed in the training
trained in sexual abuse prevention. Sexual abuse of                    sessions but did not transfer very well to ordinary situ-
individuals with mental retardation is a significant                   ations. Then training was then conducted in more every-
problem rarely discussed in the media or in the con-                   day situations with confederates (research assistants


                                                          TABLE 7
                       Selected Strategies to Develop Response Maintenance and Transfer of Training

Technique                                                                                 Brief description

Programming naturally occurring reinforcers                   After behavior has been established with a special program (e.g.,
                                                                token economy), the consequences that are more readily available
                                                                in the natural environment (e.g., attention from others) are used to
                                                                influence behavior.
Gradually removing or fading the contingencies                The intervention can be removed or faded by making the
                                                                consequences increasingly intermittent or more delayed after the
                                                                behavior is well established. Also, the intervention can be organ-
                                                                ized into levels so that as behavior is performed consistently, the in-
                                                                centives increase but there is less frequent and immediate control
                                                                the contingencies exert over behavior.
Expanding stimulus control                                    During training, the desired behavior may become associated with
                                                                specific stimulus conditions such as who administers the program,
                                                                the setting, or circumstances (e.g., time of the day). After behavior
                                                                is developed, stimulus control can be expanded by introducing a
                                                                few other instances or examples (e.g., extending the program to
                                                                more than one time). Behavior changes can be extended generally
                                                                in this way and not all conditions or circumstances of interest need
                                                                to be incorporated into training to achieve broad generalization
                                                                across conditions.
Training the general case                                     A systematic way of ensuring transfer of training by specifying the set
                                                                of stimulus situations across which a behavior is to be performed
                                                                after training has been completed, defining the range of relevant di-
                                                                mensions or characteristics across which they vary, defining the
                                                                range of response variations or the different behaviors required
                                                                across the set of stimulus situations, and selecting and teaching ex-
                                                                amples that sample from the range of the stimulus and response
                                                                domains of interest.

  Note. For elaboration of these methods, see Kazdin, 2001.
94                                              Applied Behavior Analysis

working for the study) who made approach responses.            contributes to the effectiveness of the interventions per-
As the behaviors developed, training ceased and assess-        tains to the systematic assessment and evaluation of be-
ments were made unobtrusively. The results indicated           havior-change programs. Collection of ongoing data
that the behaviors now carried over to everyday situa-         while the program is in effect allows one to make changes
tions. In addition, assessment in everyday situations          to ensure that the desired outcomes are achieved.
one month after the program ended indicated that the
behaviors were maintained. The study conveys the im-
                                                                                 Acknowledgments
portance of introducing into training the situations to
which one wants the behavior to generalize.                       Completion of this article was facilitated by support from
   Behaviors occasionally are maintained after the pro-        the Leon Lowenstein Foundation, the William T. Grant
gram is ended and transfer to novel settings, even if no       Foundation (98-1872-98), and the National Institute of Men-
                                                               tal Health (MH59029).
special procedures are in place to foster these exten-
sions. However, to ensure maintenance and transfer,
special procedures often are introduced before the pro-                See Also the Following Articles
gram is completely ended. Typically several procedures
                                                               Classical Conditioning I Conditioned Reinforcement I
(e.g., as those identified in Table 7) are combined to en-      Contingency Management I Functional Analysis of
sure maintenance and transfer and have been shown to           Behavior I Negative Reinforcement I Operant
be effective in many applications of treatment.                Conditioning I Positive Reinforcement I Response Cost
                                                               I Time-Out I Token Economy


                  VII. SUMMARY
                                                                                  Further Reading
   Applied behavior analysis refers to an approach to-         Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current
ward treatment that includes an emphasis on an-                   dimensions of applied behavior analysis. Journal of Applied
tecedents, behaviors, and consequences and how these              Behavior Analysis, 1, 91–97.
can be arranged to promote behavior change and a               Baer, D. M., Wolf, M. M., & Risley, T. R. (1987). Some still
methodological approach toward assessment and eval-               current dimensions of applied behavior analysis. Journal of
                                                                  Applied Behavior Analysis, 20, 313–328.
uation. The interventions rely on principles of operant
                                                               Bushell, D., Jr. (1978). An engineering approach to the ele-
conditioning (reinforcement, punishment, extinction,              mentary classroom: The Behavior Analysis Follow Through
stimulus control) and the scores of techniques that can           project. In Catania, A. C. & Brigham, T. A. (Eds.), Hand-
be derived from these principles. The scope of inter-             book of applied behavior analysis (pp. 525–563). New York:
ventions has been remarkable and encompasses indi-                Irvington.
viduals ranging from infants to the elderly in diverse         Iwata, B. A., Vollmer, T. R., & Zarcone, J. R. (1990). The ex-
settings (e.g., home, school, , nursing homes, facilities         perimental (functional) analysis of behavior disorders:
for delinquents, prisoners, psychiatric patients, busi-           Methodology, applications, and limitations. In Repp, A. C.
                                                                  & Singh, N. N. (Eds.), Perspectives on the use of nonaversive
nesses, and the community at large). Also, many med-
                                                                  and aversive interventions for persons with developmental dis-
ical (e.g., adherence to medication, recovery from
                                                                  abilities (pp. 301–330). Sycamore, Illinois: Sycamore.
surgery, dieting and exercise), psychological problems         Kazdin, A. E. (1978). History of behavior modification: Experi-
(e.g., various psychiatric disorders), and educational            mental foundations of contemporary research. Baltimore:
objectives (e.g., reading, academic competence) have              University Park Press.
served as target foci. The diversity of applications de-       Kazdin, A. E. (2001): Behavior modification in applied settings
rive from the generality of the principles and their              (6th edition). Pacific Grove, California: Thompson.
well-established bases in laboratory research.                 Miltenberger, R. G., Roberts, J. A., Ellington, S., & Galensky, T.
   Implementing the techniques that derive from the               (1999). Training and generalization of sexual abuse preven-
principles represents a significant challenge. Altering the        tions skills for women with mental retardation. Journal of
                                                                  Applied Behavior Analysis, 32, 385–388.
contingencies of reinforcement has special requirements
                                                               Paul, G. L., & Lentz, R. J. (1977). Psychological treatment of
if behavior change is to be achieved. Consequently, the           chronic mental patients: Mileu versus social learning pro-
seeming simplicity of the interventions is deceptive. A           gram. Cambridge, MA: Harvard University Press.
program involving praise or token reinforcement for be-                       .
                                                               Skinner, B. F (1953). Science and human behavior. New York:
havior can easily succeed or fail based on how systemati-         Free Press.
cally and consistently the consequences are provided.                      .
                                                               Sturmey, P (1996). Functional analysis in clinical psychology.
The special feature of applied behavior analysis that also        Chichester, England: John Wiley & Sons.
                                     Applied Relaxation
                                                      Lars-Göran Öst
                                                       Stockholm University




    I.   Description of Applied Relaxation                             ney in 1976 and later extensively developed by Lars-
   II.   Theoretical Basis for Applied Relaxation                      Göran Öst during the late 1970s and early 1980s. Applied
  III.   Applications and Exclusions                                   relaxation takes as its starting point the abbreviated pro-
  IV.    Empirical Studies                                             gressive relaxation (PR) developed by Joseph Wolpe in
   V.    Summary
                                                                       the 1950s as part of systematic desensitization. However,
         Further Reading
                                                                       PR is not suitable as a coping technique since it takes
                                                                       15–20 minutes for the patient to go through the various
                                                                       muscle groups in order to become relaxed. The relaxation
                            GLOSSARY                                   has to be reduced into a “portable” skill that patients can
                                                                       use in any situation when needed. Applied relaxation is a
application training The use of rapid relaxation in anxiety-
   arousing situations to reduce and eventually abort anxiety          technique that in a number of steps teaches patients to
   reactions.                                                          relax rapidly, the goal being 20–30 seconds, in natural sit-
cue-controlled relaxation The association of the cue “Relax”           uations where their problems occur.
   with the state of relaxation.                                          The first step of PR training, usually takes 2 weeks of
differential relaxation Practicing being relaxed in those mus-         practice and the time to become relaxed is 15–20 min-
   cles not necessary to tense for the activity at hand.               utes. The second step, release-only relaxation, is com-
progressive relaxation The tensing and relaxing of 23 major            monly practiced for 1 week and the time to relaxation is
   muscle groups.                                                      reduced to 5–7 minutes. The third step, cue-controlled
rapid relaxation A very brief relaxation used in natural situa-        relaxation, also requires a week of practice, and relax-
   tions to become relaxed quickly (20–30 seconds).
                                                                       ation is achieved in 2–3 minutes. The fourth step is dif-
release-only relaxation Relaxing the muscle groups without
                                                                       ferential relaxation, which is practiced for 2 weeks and
   the prior tension.
                                                                       relaxation is achieved in 1 minute and the time is re-
                                                                       duced to 1 minute. The fifth step, rapid relaxation, is
                 I. DESCRIPTION OF                                     also practiced for 2 weeks allowing the patient to be-
                APPLIED RELAXATION                                     come relaxed in 20–30 seconds. The final step, applica-
                                                                       tion training, usually takes 2 weeks, and now the rapid
                                                                       relaxation is used in natural anxiety-arousing situations.
                 A. General Features of
                  Applied Relaxation                                   1. Rationale for AR
  Applied relaxation (AR) is a cognitive-behavioral cop-                 In any cognitive behavior therapy it is important that
ing technique first described by Chang-Liang and Den-                   patients understand the rationale for the treatment in



Encyclopedia of Psychotherapy                                                                       Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                          95                                                    All rights reserved.
96                                                  Applied Relaxation

question. The therapist should give an easily under-            In the final phase, application training, you apply the
standable theoretical description regarding the patient’s       skill of relaxing rapidly in those situations in which
problem and a description of how AR is scheduled and            panic symptoms occur. Over the 8–10 weeks of train-
supposed to work. When presenting the treatment ra-             ing you record your panic attacks in the panic diary.
tionale it is also useful to give the patients a written        This monitoring results in a lot of information about
version (1–2 pages) that they can read during the pres-         the first signs that tell you a panic attack is coming on.
entation and take home to examine more carefully.               By applying rapid relaxation as soon as you experience
Below is an example of a rationale that might be used in        the first sign you will learn that you can stop the anxi-
the treatment of a person with panic disorder.                  ety symptoms from escalating to a high level. After a
   During a panic attack your are likely to feel very anx-      few weeks you will be able to abort the first signs or
ious and experience a lot of symptoms, such as palpita-         symptoms altogether. When the panic attacks have dis-
tions, muscle tension, sweating, breathlessness, and            appeared you will have the opportunity to follow a
dizziness. Usually, the attack seems to come “out of the        maintenance program to keep your relaxation skill fine
blue” in other words without warning, making you                tuned and ready to apply whenever you may need it in
want to leave the situation. As you leave and get home          the future.
to safety the symptoms dissipate, but you are usually              After the therapist has provided the treatment ration-
exhausted and fear what will happen the next time you           ale patient questions are answered. The patient is then
have a panic attack.                                            encouraged to take the written description home and
   There is a treatment method called AR that can help          read it carefully in order to discuss it with the therapist at
you cope with and eventually stop the anxiety symp-             the next session, during which time the treatment starts.
toms altogether. The first thing you do in this treatment
is to observe your panic attacks in order to become             2. Homework Assignments
aware of the very first sign(s) of a panic attack coming            Since therapists usually only see patients once a week,
on. The observations are recorded in a panic diary, and         the relaxation training requires that patients practice at
over the next couple of months you will realize that            home twice per day the skills presented in session. Prac-
even if the panic attack starts rapidly there is usually a      tice is recorded on self-monitoring forms provided by
period of 30–60 seconds between the first sign and the           the therapist. On these forms the patient records the de-
full-blown panic attack. It is during this period you           gree of relaxation experienced immediately before and
have a chance to do something to prevent the symp-              after the practice, the approximate duration of the prac-
toms from developing further, such as “to nip it in the         tice, and any comments the patient may have. The scale
bud.” Thus, these signs are used as an “alarm clock” to         for rating the degree of relaxation is a 0–100 scale, where
apply a relaxation technique that will counteract the           50 is the “normal state” (neither relaxed nor tense). A 0
anxiety symptoms.                                               means complete relaxation and 100 means maximal ten-
   Most patients wonder how it is possible to relax in          sion/anxiety. The same form is used for the first four
such a short time? What you do in AR is to start by             steps of AR training, while alternative forms are used
learning PR which takes 15–20 minutes. In PR you                during rapid relaxation and application training.
briefly tense and then relax the big muscle groups of               It is also important to realize that it is rare to find pa-
your body. After practicing that for two weeks you then         tients that can complete every weekly practice assign-
work on relaxing by using the release-only procedure,           ment. Patients are instructed to make a note regarding
omitting the muscle tensing portion of the technique.           the reason for missing a practice session. Furthermore, it
This reduces the time it takes for you to get relaxed to        is emphasized that it is better to practice only once a day
5–7 minutes. The next step is called cue-controlled re-         in a calm and nonstressful situation than twice a day if
laxation, a step in which you learn to associate the self-      both practice occasions are carried out during a fairly
instruction “Relax” with the state of relaxation. Then          high level of time pressure. If patients do not have time
follows differential relaxation with the purpose of             to practice more than once a day, treatment will take
teaching you to do various activities while being re-           longer.
laxed in the muscles that don’t have to be actively en-
gaged in those activities. In this phase you might              3. Transitions
practice relaxing while sitting, standing, and walking.            Patient records of the relaxation training progress at
The next step is called rapid relaxation, which usually         home serve as the therapist’s guide in deciding when it
takes 20–30 seconds, and during this step you practice          is time to proceed to the next step in treatment. When
to relax in natural, but not anxiety-arousing situations.       patients experience an average increase in relaxation
                                                       Applied Relaxation                                                97
from immediately before to after homework practice of              The method involves learning to relax by first tensing
20–30 points, such as a prerating of 50 and a postrating           and then relaxing different muscle groups in the body.
of 20–30 on the 0–100 scale, it is time to continue. It is         Briefly tensing muscles makes it easier to experience
not necessary for patients to achieve very high levels of          the contrast between a tensed and a relaxed muscle,
relaxation (ratings of 0–10) in order for the AR skill to          and to notice tension in various muscles during daily
be acquired.                                                       activities. The different muscle groups that are in-
                                                                   cluded can be conceived of as a menu from which pa-
             B. Observation of Early                               tients can choose. There is absolutely nothing sacred
                 Signs of Anxiety                                  about the constellation of muscle groups. The impor-
                                                                   tant thing is that as patients achieve a high degree of
   In order for applied relaxation to work optimally               relaxation, they need not always follow the PR instruc-
patients must use the relaxation technique as early as             tions to the letter. For some patients the tensing/releas-
possible in the response to an anxiety reaction or a               ing of a certain muscle group can lead to an experience
panic attack. Reacting quickly to the first signs of anx-          of increased tension in that muscle. If that is the case,
iety greatly increases the patients’ ability to employ             that particular muscle group may be deleted from the
AR effectively. In order to increase the patient’s aware-          relaxation training.
ness of the initial signs of anxiety, homework assign-                Progressive relaxation training begins with demon-
ments involve observing and recording these                        strating to patients exactly how the different muscle
reactions. In the panic diary the patient records the              groups are to be tensed and relaxed. The therapist sits
situation, the symptoms of the panic attack, and the               opposite the patient and models the procedure across
severity of the attack (0–100), as well as the very first          the different muscle groups, while the patients simulta-
signs that were experienced.                                       neously perform these behaviors. Below is a list show-
   Therapist and patient examine the panic diary and               ing the muscle group and the order in which
focus on identifying the earliest signs of the onset of the        tensing/relaxing exercises are presented.
panic attacks. An attempt is made to determine what the
patient felt, thought about, or did just before the first            1.   Tense your right hand (make a tight fist)
symptom occurred. Sometimes it can be advantageous                  2.   Tense your left hand (make a tight fist)
to let patients imagine their most recent panic attack.             3.   Tense both hands (make tight fists)
This procedure often assists patients in remembering                4.   Tense your biceps
things that they did not notice while recording the ac-             5.   Tense your triceps (stretch your arms without lift-
tual attack. Besides making the patient more aware of                    ing them)
the early signs of anxiety, it is important to get an ap-           6.   Wrinkle your forehead by raising your eyebrows
proximate estimate of the time between the first sign                7.   Wrinkle your eyebrows (bring them tight to-
and the peak of the panic attack. As patients realize that               gether)
this time period is perhaps as long as 30 seconds to sev-           8.   Close your eyes tight
eral minutes, confidence that they will be able to apply             9.   Tense your jaw muscles by biting your teeth
AR to the early signs of anxiety and prevent it from de-                 together
veloping into a panic attack begins to grow.                       10.   Push the tip of your tongue against the roof of
   It is valuable to collect and summarize the reported                  your mouth
early signs of anxiety. These recordings provide a data-           11.   Press your lips together
base for use later in treatment. In particular, in the appli-      12.   Push your head back against the top of the chair
cation phase of AR these data will allow the therapist to          13.   Bend your head forward, touching your chin to
present to patients a systematic summary of early signs                  your chest
ranked by frequency and perhaps divided according to               14.   Raise your shoulders towards your ears
some systematic grouping. This list will prove useful as           15.   Raise your shoulders towards your ears, and move
patients begin to apply AR in real life situations.                      them in a circular motion
                                                                   16.   Breathe with calm regular breaths
           C. Progressive Relaxation                               17.   Take a deep breath; fill your lungs and hold your
                                                                         breath
   Before starting PR training, patients should be given           18.   Tighten your stomach muscles
a rationale for the PR. It should be noted that PR is eas-         19.   Pull your stomach inward
ily learned and does not require any special abilities.            20.   Bend your back in a curve
98                                                   Applied Relaxation

21. Tense your thighs by pressing your heels to the                       E. Cue-Controlled Relaxation
    floor
22. Point your feet and toes down (forward)                         The purpose of cue-controlled relaxation (CR) is for
23. Point your feet up towards your face                         the patient to learn to associate the self-instruction
                                                                 “relax” with a relaxed state, and further reduce the time
   During relaxation training patients are prompted to           it takes to become relaxed. Cue-controlled relaxation
sit as comfortably as possible, loosen tight fitting             may be introduced to patients as follows: “Most of us
clothes, and close their eyes. Room lights can be                have probably been in situations where we or an ac-
dimmed and the therapist’s tone of voice should be low           quaintance have been very nervous. In that situation
and somewhat monotonous, without being sleep in-                 we often get the advice to ‘take it easy and relax.’ This
ducing. Furthermore, it is important to remember that            advice very seldom works since it is given when we are
it is the relaxation and not the tension that is the im-         already mentally and physically at a high arousal level.
portant part of PR. The tension is only included as a            In order to relax in these situations you must practice
contrast to the relaxation. The relation between the du-         pairing the relax self-instruction with the relaxed state.
ration of time the patient tenses and relaxes the differ-        Once you can successfully make yourself relaxed, you
ent muscle groups must be 1:2 or 1:3; that is, if a              then need to start practicing this cued relaxation in in-
muscle is tensed for 5 seconds, the following relaxation         creasingly more stressful settings.”
interval should be at least 10–15 seconds.                          The session starts by the patient relaxing on their
                                                                 own with the help of the release-only version of PR,
                                                                 which the patient has been practicing for 1–2 weeks.
          D. Release-only Relaxation                             When having achieved a deep degree of relaxation the
   The introduction provided before the start of the re-         patient signals the therapist by lifting one index finger.
lease-only phase of PR is that this step is intended to re-      Focus in CR is on the breathing and in following the
duce the time it takes for the patient to become relaxed         therapist’s instructions on the pace of their breathing
from 15–20 minutes with the PR to about 5–7 minutes,             pattern. Just before breathing in, the therapist says “in-
and to help them learn to relax without having to tense          hale” and just before breathing out, the therapist says
muscle groups. Patients are told they will be instructed         “relax.” This is done 4–5 times. Then the patient is in-
to focus on the different parts of the body and are asked        structed to think “inhale” and “relax” silently in pace
to relax as much as possible. If, after having tried to          with the breathing rhythm. After the patient has been
relax they still feel tension in a muscle, they should           doing this on their own for about 2 minutes, the thera-
tense the muscle briefly and then relax it (such going            pist comes back with the instruction “inhale … relax” a
back to the procedure used during the PR). During this           further 4–5 times, after which the patient takes over
phase of training the therapist adjusts the instruction          and does this exercise covertly for a couple of minutes.
to a pace which allows patients time to perform the ten-         This practice sequence only takes about 10 minutes
sion-release exercises when necessary.                           and after a break of 10–15 minutes during which one
   Below is an example of the instructions used in this          can do other things (such as going over the panic
phase: “Breathe with calm, regular breaths and feel how          diary), it is suitable to repeat the entire instruction dur-
you relax more and more with each breath … Just let go           ing the session.
…. Relax your forehead … eyebrows … eyelids … jaws
… tongue and throat … lips … and your entire face ….
                                                                            F. Differential Relaxation
Relax your neck … shoulders … arms … hands … and
all the way out to your fingertips …. Breathe calmly and          1. Introduction to Differential Relaxation
regularly … and let the relaxation spread to your stom-            In order for AR to be an effective coping skill it must
ach … waist and back …. Relax the lower part of your             be “portable,” The patient should be able to use it in
body, your buttocks … thighs … calves … feet … and all           practically any situation and not be constricted to a
the way down to the tips of your toes …. Breathe calmly          comfortable armchair in the home or in the therapist’s
and regularly and feel how you relax more and more               office. The primary purpose of differential relaxation
with each breath … Continue to relax like that for a             (DR) is to teach the patient to relax in other situations
while …. [Pause for about 1 minute.] Now take a deep             besides in the comfortable armchair. The secondary
breath, hold it … and let the air out slowly … slowly …          purpose of DR is to learn not to be tense in the muscle
Notice how you relax more and more.”                             groups not being used for the activity at hand.
                                                    Applied Relaxation                                                 99

2. Instruction of Differential Relaxation                       when signaling to the therapist, before starting to do
   The session starts with the patient sitting in the arm-      the movements, and after all the exercises have been
chair relaxing on their own with the help of CR. When           completed. What you often find is that the patient has
the patient has signaled that they are relaxed, they then       achieved a good degree of relaxation and performing
follow the instruction to perform certain movements             the movements has not led to less relaxation; in many
with different parts of the body while at the same time         cases the relaxation has instead been deeper after the
concentrating on being as relaxed as possible in the rest       exercises. You should also ask the patient to estimate
of the body. During the performance of these move-              how long it took them to become relaxed, which al-
ments the patient should scan the body often (i.e., think       most always gives the instructor the chance to praise
through the different muscle groups) in order to dis-           the patient for achieving the relaxation in a shorter
cover possible tensions, and in that case they should           time than was estimated.
relax away these tensions. After the patient has signaled
that they are relaxed the following instruction is given.       3. Further Steps in Differential Relaxation
   “Continue to relax as much as possible in the entire            After practicing in an armchair, the same procedure
body. While you do that … open your eyes and look               is repeated while the patient is sitting in an ordinary
around in the room without moving your head. Look               chair. Then you can let the patient sit in an office chair
to your left … and to your right … up to the ceiling …          by a desk and perform various activities that are natural
and down to the floor. Concentrate on relaxing as                to that situation, such as writing, typing, and making
much as possible in the rest of the body … Now do the           phone calls. These three components usually cover one
same thing but also turn your head in order to take in a        session and during the next session you proceed by
larger field of vision. Look to the left … and to the right      teaching the patient to relax while standing, and doing
… up to the ceiling and down to the floor. Good! Take            the same activities as while sitting, except for the use of
the head back to a comfortable position and relax as            their legs. Finally, the patient should practice being re-
much as possible. Let your arms rest against the elbow          laxed while walking. In this situation it is an advantage
rests and now lift the right hand a bit from the support.       to have a fairly long corridor to practice in.
Concentrate on the relaxation in the left hand and arm
… now stretch the arm straight out … and straight up
                                                                               G. Rapid Relaxation
in the air … focus on the relaxation in the left arm …
and now take the right arm back to a comfortable posi-          1. Introduction to Rapid Relaxation
tion on the armrest. Relax as much as possible in your             The purposes of rapid relaxation (RR) are to teach
right arm and do the same thing with the left arm. Lift         the patient to relax in natural but not anxiety-arousing
the left hand a little bit from the armrest. Concentrate        situations, and to further reduce the time it takes to be-
on the relaxation in the right hand and arm … Now               come relaxed. The goal for this is 20–30 seconds. In
stretch the arm straight out … and straight up in the air       order to reach these goals the patient should use rapid
… Focus on the relaxation in the right arm … and take           relaxation 15–20 times a day in natural situations. At
the left arm down to a comfortable position on the arm-         this stage it is very important that the therapist spends
rest. Relax as much as possible in the left arm and the         some time to thoroughly go over the goals with the pa-
entire body … Now bend the right foot up towards the            tient and to write down suitable situations that func-
face while you concentrate on relaxing in the left foot         tion as signals for RR training. The therapist asks the
… and stretch the right leg straight out. Focus on the          patient to describe what an ordinary day looks like to
relaxation in the left leg … and take the right leg down        them and what they do between getting out of bed in
and relax. Relax as much as possible in the right leg           the morning through going to bed at night. Among
and now do the same thing with the left leg. Bend the           those activities that the patient does one can choose
left foot up towards the face while you concentrate on          signal situations in such a way that it make up at least
relaxing in the right foot … and stretch the left leg           15 practice occasions per day.
straight out. Focus on the relaxation in the right leg …
and take the left leg down and relax. Relax as much as          2. Instruction of Rapid Relaxation
possible in the left leg and the entire body; the head,           When the patient is relaxing in natural situations
the arms, the chest, and legs.”                                 during this phase of AR the relaxation has largely been
   After finishing the instruction you should ask the pa-        reduced. The patient is instructed and the therapist
tient to note the degree of relaxation after using CR           models the following sequence:
100                                                     Applied Relaxation

1. Take a deep breath and slowly let the air out                    For these patients it is enough to give them a rationale
2. Think “relax” quietly each time you breathe out                  before starting the application training. This is to get
3. Scan your body for any signs of tension and relax as             their expectations at the right level, after which they
   much as possible in the situation                                are confident enough to start applying the relaxation
4. Stay in the relaxed state for 30–60 seconds.                     skill in real life panic situations.
                                                                       In some panic patients it has turned out to be useful
   If, after doing all the above, the patient still feels that      to provoke a “mini-attack” during therapy for which
they haven’t achieved a deep enough degree of relax-                one can practice applying AR. In this situation different
ation, one can take one more deep breath as described               methods to provoke a panic reaction can be used and
above. In some cases the entire sequence can be re-                 the choice of the method used is dependent on which
peated for a third time. After this the patient should be           of the techniques most readily provoke panic symp-
content with the degree of relaxation achieved. Other-              toms in the patient. Voluntary hyperventilation during
wise there is a risk that the patient will trigger symp-            1–2 minutes with 30 breaths per minute will in
toms of hyperventilation, which of course counteracts               50–60% of the patients produce symptoms that remind
the purpose of RR.                                                  them of, or are the same as, a naturally occurring panic
                                                                    attack. If this technique is used, it is appropriate to let
                                                                    the patient breath normally using stomach breathing
             H. Application Training
                                                                    instead of taking a deep breath at the beginning of
1. Introduction to Application Training                             rapid relaxation, since the latter might be a continua-
   The only rationale you give the patient at this stage is         tion of the hyperventilation. Another technique that
that it is now time to start practicing in reality what they        can be useful in some patients is using physical exer-
have learned in theory. Before starting this phase it is            cise such as letting the patient run up and down the
very important to give the patient an instruction that sets         stairs for a couple of minutes in order to get them to
their expectations at the right level. You remind the pa-           palpitate, which in turn one fears is the beginning of a
tient that applied relaxation is a skill and as with any            panic attack. In patients where dizziness is an impor-
other skill it takes practice to refine it. This means that          tant panic symptom one can spin the patient around on
the patient should not expect that AR functions at 100%             an office chair for 20–30 seconds.
the first time it is applied, such as with a panic attack. In-          One further possibility is to let the patient imagine a
stead, one must be satisfied with the anxiety not increas-           difficult panic attack that has occurred to them before
ing as much as it had before, but that it levels out at a           or during treatment. In this situation it is suitable to
mild to moderate level. It is very important that the pa-           have the therapist describe the situation and the panic
tient does not get demoralized but that they continue to            symptoms to the patient and letting the patient signal
apply AR every time they are in an anxiety situation. Rel-          by raising a finger when they experience the first sign of
atively soon one will notice an effect from AR, and even-           anxiety in the current situation. When the patient has
tually the anxiety reactions will dissipate altogether.             signaled, one should let them keep the image of that sit-
   Before the patient goes out into real life situations            uation for a while (4–5 seconds) and then you should
and starts applying the relaxation in these situations,             instruct the patient to stop thinking about the described
one must go over the list of early signs that the thera-            situation and use AR to counteract the reactions.
pist has put together during the course of the treat-
ment. First, the patient should try to describe by heart
the early signs that have been recorded during their                         II. THEORETICAL BASIS FOR
panic attack. Second, the patient should be given the                            APPLIED RELAXATION
list that the therapist has collected as a memory aid for
them to start applying the relaxation technique in real-               So far there are no developed theoretical models to
life situations. In this way, the patient’s awareness of            explain the mechanism of AR. However, it is possible to
these early signs is increased directly during the phase            use a modification of the type of vicious circle explana-
where the application is going to take place.                       tion that has been developed for cognitive therapy in
                                                                    panic disorder. This model assumes that independently
2. Practical Application Training                                   of what kind of a eliciting stimulus or what type of ini-
  A majority of panic patients do not think that they               tial reaction follows there is an interaction between
have a need for any special form of application training.           physiological and cognitive reactions, culminating in a
                                                     Applied Relaxation                                               101
panic attack. The purpose of AR is to break the vicious          have evaluated AR for stress reactions, insomnia,
circle as quickly as possible in order to stop the first          menopausal symptoms, genital herpes and as a stress-
signs of anxiety from escalating into a panic attack. As         management technique for collegiate field hockey play-
the patient starts using the application skill they are          ers, soccer players, and novice rock climbers.
fully occupied by concentrating on that skill and thus              In some of the disorders, not including anxiety, a
the probability is lower that the chain of negative              combination of AR and other behavioral methods have
thoughts will start to develop.                                  been used. In general, AR seems to be a suitable treat-
   Since there are no studies regarding the mechanism            ment method for problems where the main component
of change for AR at this time one can only speculate             is anxiety or stress reactions, or at least is an important
concerning this issue. Personally, I believe that AR             part of the problem. Different physiological reactions
works through the patient having acquired the skill to           should also be part of the problem picture of the pa-
rapidly achieve a state of relaxation, which counteracts         tient.
the anxiety reactions both on a physiological and a cog-            So far there are no direct contraindications in the re-
nitive level. Perhaps Bandura’s self-efficacy theory can          search or clinical application of AR. The fact that AR
be used in this regard. There are at least three con-            has been used for schizophrenic patients, without the
tributing factors which cannot be disregarded:                   predicted “psychotic breakthrough” that psychody-
                                                                 namic therapists talk about, speaks for its utility in a
   1. The reduction of the general tension level in the          wide range of psychiatric, psychosomatic, and somatic
body. As this happens the probability is reduced that            problems.
small stressors will, when they are added to the ambi-
ent tension level, lead to the patient ascending over the
panic threshold.                                                             IV. EMPIRICAL STUDIES
   2. Increased awareness and knowledge about anxiety
reactions. As the patient learns to identify early signs of         There are 33 studies published between 1981 and
anxiety they will learn more about what anxiety is and           2000, 15 of those studies included various anxiety dis-
experience it in a more differential way instead of a “big       order patients, while the remaining 18 focused on dif-
black lump” or “lightning out of the blue.”                      ferent somatic disorders (headache, pain, epilepsy,
   3. Increased self-confidence. By using the relaxation          tinnitus, Ménière’s disease, hearing impairment, dys-
skill in natural situations and noticing that it works,          pepsia, and cancer).
one can reduce or abort the anxiety altogether. The pa-             In 19 of the studies, AR was compared to a control
tient develops an increased confidence in their own               condition (waitlist or attention-placebo). In all in-
ability to do something proactive. The patient is no             stances, AR yielded significantly better results.
longer a helpless victim of panic.                                  These studies contain 28 comparisons between AR
                                                                 and another active treatment. AR was found signifi-
                                                                 cantly more effective then progressive relaxation in
                III. APPLICATIONS                                panic disorder, than cognitive treatment in agorapho-
                AND EXCLUSIONS                                   bia, and nondirective therapy in generalized anxiety
                                                                 disorder. AR was less effective than cognitive therapy in
   Applied relaxation is a coping technique that was             two studies of panic disorder.
primarily developed for the treatment of nonsituational             AR was found as effective as exposure in claustro-
anxiety or panic attacks. However, research and clinical         phobia, blood phobia, and agoraphobia; as with cogni-
applications show that it is a method that is useful for         tive therapy in panic disorder, GAD, and tinnitus; as
many different disorders.                                        with self-instructional training in social phobia and
   In randomized clinical trials, AR has been evaluated          dental phobia; as with social skills training in social
for specific phobias such as social phobia, agoraphobia,          phobia; as with applied tension and the combination of
panic disorder, generalized anxiety disorder, tension            AR and applied tension in blood phobia; as with
headache, mixed headache, migraine, pain (low back               imipramine in panic disorder; as with anxiety manage-
and upper extremities), epilepsy, tinnitus, Ménière’s            ment training for anxiety in schizophrenic patients;
disease, hearing impairment, nonulcer dyspepsia, and             as with the combination of AR and cognitive therapy
also to improve the immune defense system in cancer              in GAD; as with progressive relaxation in mixed
patients. Furthermore, nonrandomized pilot studies               headache; as with biofeedback and the combination of
102                                                 Applied Relaxation

AR and biofeedback in pain; as with the combination of          and cancer. A summary of the randomized clinical tri-
AR and an operant program in pain; and as with tran-            als shows that AR is significantly more effective than
scutaneous nerve stimulation in Ménière’s disease. Fi-          control conditions and as effective as various well-es-
nally, the combination of AR and an operant program             tablished treatment methods with which it has been
was as effective as CT and the operant program, and             compared. Follow-ups, on average 11 months after the
the operant program alone, in pain patients. This com-          end of treatment, show that not only have the treat-
bination was also more effective than regular treatment         ment effects been maintained, but also on average there
in another study of pain patients.                              is a further improvement.
   The conclusion that can be drawn from this is that
(with two exceptions) AR is more effective than, or as
effective as, other well established treatment methods                   See Also the Following Articles
for various anxiety disorders and psychosomatic/so-             Anxiety Management Training I Applied Tension I
matic disorders.                                                Behavioral Treatment of Insomnia I Homework I
   Twenty-four of the 33 studies report follow-up re-           Progressive Relaxation I Relaxation Training I Restricted
sults on average 11 (range 4–24) months after the com-          Environmental Stimulation Therapy I Stretch-Based
pletion of treatment. A comparison of the percent               Relaxation Training
improvement on the most important measure in each
study showed that the mean pre-post change was 53%                                 Further Reading
and the mean pre-follow-up change was 60%. Thus,
not only were the treatment effects for AR maintained           Borkovec, T., & Whisman, M. (1996). Psychosocial treat-
                                                                   ment for generalized anxiety disorder. In M. Mavis-
almost a year after treatment, but there was a small fur-
                                                                   sakalian, & R. Prien (Eds.), Long-term treatments of anxiety
ther improvement during the follow-up period.                      disorders (pp. 171–199). Washington, DC: American Psy-
                                                                   chiatric Press.
                                                                Chambless, D. L. & Gillis, M. M. (1994). A review of psy-
                   V. SUMMARY                                      chosocial treatments for panic disorder. In B. E. Wolfe, &
                                                                   J. D. Maser (Eds), Treatment of panic disorder: A consensus
   Applied relaxation is a coping technique consisting             development conference (pp. 149–173). Washington, DC:
of a series of steps which teaches the patient to reduce           American Psychiatric Press.
the time it takes to become relaxed from 15–20 min-             Clark, D. M. (1989). Anxiety states: Panic and generalized
utes to 20–30 seconds and to apply this skill in natu-             anxiety. In K. Hawton (Eds.), Cognitive behaviour therapy
rally occurring anxiety situations. The treatment                  for psychiatric problems: A practical guide. (pp. 52–96). Ox-
                                                                   ford, UK: Oxford University Press.
usually takes 8–10 weeks to complete and clinical ex-
                                                                         .,
                                                                Fisher, P & Durham, R. (1999). Recovery rates in general-
perience and research show that 90% of the patients ac-            ized anxiety disorder following psychological therapy: An
quire the skill of being able to relax rapidly. While first         analysis of clinically significant change in the STAI-T
developed for nonsituational anxiety disorders, AR has             across outcome studies since 1990. Psychological Medicine,
successfully been applied to other anxiety disorders as            29, 1425–1434.
well as various psychosomatic and somatic disorders,            Linton, S. (1994). Chronic back pain: Activities training and
such as headache, pain, epilepsy, tinnitus, dyspepsia,             physical therapy. Behavioral Medicine, 20, 105–111.
                                         Applied Tension
                                                      Lars-Göran Öst
                                                       Stockholm University




    I.   Description of Applied Tension                                 case study and later developed within Öst’s research proj-
   II.   Theoretical Basis for Applied Tension                          ect on the treatment of blood-injury-injection phobia. It
  III.   Applications and Exclusions                                    consists of two components: the learning of an effective
  IV.    Empirical Studies                                              tension technique, and the application of this technique
   V.    Case Illustration
                                                                        while being exposed to blood-injury stimuli. In its origi-
  VI.    Summary
         Further Reading                                                nal form AT is a five-session treatment with homework
                                                                        assignments to carry out between sessions, but later re-
                                                                        search has shown that a one-session (2 hours) version is
                            GLOSSARY                                    as effective. Both versions will be described.

application training The application of the tension technique
   when experiencing the early signs of a blood pressure drop                          B. The Physiological
   while being exposed to blood stimuli.                                                Response Pattern
blood-injury-injection phobia The fear and avoidance of see-
   ing blood, injuries or receiving an injection or other inva-            When a patient with a specific phobia encounters the
   sive medical procedures.                                             phobic stimuli the typical response pattern is an imme-
diphasic pattern The initial increase followed by a sharp de-           diate activation of the sympathetic branch of the auto-
   crease of blood pressure when exposed to blood stimuli.              nomic nervous system (i.e., increase of heart rate,
early signs The very first (idiosyncratic) signs that the blood          blood pressure, skin conductance, etc.). If the patient
   pressure is dropping.                                                remains in the situation there is a gradual reduction
tension technique The tensioning of the arms, the chest, and            back to baseline levels. In contrast to this, patients with
   the leg muscles.                                                     blood-injury phobia, and to a lesser extent those with
                                                                        injection phobia, usually show a diphasic pattern. After
                                                                        an initial increase in blood pressure and heart rate there
                    I. DESCRIPTION OF
                                                                        is a sharp decrease in these variables, which eventually
                    APPLIED TENSION                                     leads to fainting when the cerebral blood pressure has
                                                                        fallen below a critical level. This is illustrated by Figure
                 A. General Features of
                                                                        1 describing the blood pressure of a blood phobic pa-
                    Applied Tension                                     tient treated in our clinic. The 10-minute baseline
  Applied tension (AT) is behavioral coping technique,                  shows a rather stable systolic blood pressure (SBP)
first described by Kozak and Montgomery in 1981 in a                     around 120 mmHg and diastolic blood pressure (DBP)



Encyclopedia of Psychotherapy                                                                        Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                          103                                                    All rights reserved.
104                                                      Applied Tension




                 FIGURE 1 Systolic (SBP) and diastolic (DBP) blood pressure during the different phases of the
                 blood phobia test situation. Baseline = 10 minutes rest, Instr. = instruction about the upcoming
                 test and waiting for it, Test = watching a 30-minute videotape of thoracic surgery, Post-baseline
                 = 10 min of recording after the patient had regained consciousness, F = fainting.



around 80 mmHg. During the 4-minute instruction                         also reduced and before fainting you will feel dizziness
phase there is an increase in both SBP (to 135) and DBP                 and other fainting sensations. In order to reverse this
(to 100), which is continued during the first assess-                    progression you need to acquire a coping skill that can be
ment of the test period (150 and 110, respectively)                     applied rapidly in any situation which triggers these sen-
                                                                        sations. Applied tension is this skill which produces an
when the patient is watching a videotape of thoracic
                                                                        increase in blood pressure and cerebral blood flow. The
operations. This is the first phase of the diphasic reac-
                                                                        method has three parts: (1) learning the actual tension
tion. Then there is a drop in both SBP (to 95) and DBP                  technique, (2) learning to identify the very first signs of
(to 55) 10 minutes into the tape when the patient                       the drop in blood pressure, and (3) applying the tension
fainted. This is the second phase. During the post-base-                technique when being exposed to various blood-injury
line there is a gradual recovery back to baseline levels.               stimuli that trigger the fainting sensations. The tension
   There are different hypotheses in the literature at-                 technique consists of tensioning the large body muscles;
tempting to explain this diphasic response pattern but                  the arms, the chest, and the legs for short periods of time.
so far none has very much research evidence.                            By being exposed to different stimuli under my supervi-
                                                                        sion you will gradually be more and more efficient at
                                                                        identifying the early signs and apply the tension tech-
               C. Rationale for AT                                      nique so that the reduction in blood pressure will not be
                                                                        so dramatic, and you will get the curve to turn upward.
  After having described the diphasic pattern the ther-                 The tension technique is easy to learn but like any other
apist gives the following explanation of how AT is                      skill it takes practice to master it. You cannot expect to be
going to work.                                                          perfect at it at once but with experience you will be bet-
                                                                        ter and better. The goal is that you should be able to en-
     Since the second phase of the response consists of the             counter these situations without having stronger
  drop in blood pressure your blood flow in the brain is                 reactions than people in general.
                                                       Applied Tension                                                105
  After giving a rationale like this the therapist should        problem that a few of our patients have reported while
encourage the patient to ask questions if there is some-         carrying out the homework is headache. This is probably
thing that is not clear to him or her. One frequently            due to a tension that is too intensive and/or too frequent,
asked question is what happens if the first signs come            and is solved by instructing the patient to reduce both
on very rapidly and I am not good or quick enough to             intensity and frequency of the tension practice.
prevent the fainting; will everything be in vain? The
answer is that it is no disaster if you faint during a ther-     2. The Second and Third Sessions
apy session. On the contrary, this will give you the op-            During the second and third session the patient is
portunity to practice applying the tension technique as          shown a series of slides (about 30) of wounded or mu-
soon as you regain consciousness. Then you will learn            tilated people. When the first slide is shown on the
that you recover much more rapidly than you have                 screen in front of the patient he or she is instructed to
done so far, in 15 to 20 minutes instead of 3 to 4 hours.        introspect and scan for the very first sign that the blood
                                                                 pressure is dropping, while watching the picture. As
                                                                 soon as the first symptom is detected the patient de-
   D. Outline of the Treatment Program                           scribes what it is, and if the reaction is not too strong
1. The First Session                                             the therapist assesses the patient’s blood pressure to ob-
   The initial part of session 1 consists of a behavior          tain a pretensing level. Then the patient applies the ten-
analysis concerning the patient’s experiences when en-           sion and keeps applying it (with brief periods of
countering blood-injury stimuli. This should focus on            release) until he or she can watch the slide without ex-
what the patient usually does in the situation, if he or         perincing the symptom. Then the therapist once more
she has fainted, how often this has occurred, how long           assesses the blood pressure to obtain a post-tensing
the patient has been unconscious, and particularly               level, and at the end of the session pre- and post-tens-
what were the symptoms that the patient experienced              ing levels can be compared. When the patient can
before fainting. These early signs can be idiosyncratic,         watch the slide for about a minute it is time to continue
for example, dizziness, cold sweat, tunnel vision, ring-         with the next slide and repeat the process. The aim is to
ing in the ears, a queasy sesation in the stomach, and           complete the first 15 slides during session 2 and con-
nausea. It is important to list these symptoms carefully         tinue with the next 15 slides during session 3.
and in their order of occurrence since they are used as             During these two sessions the job of the therapist is
cues for applying the tension in later sessions. After           very similar to a sports coach: setting the stage for the
having completed the behavior analysis the therapist             initial BP drop, encouraging the patient to observe the
describes the rationale as outlined earlier.                     first signs, and coaching him or her to apply the ten-
   The last part of the first session consists of teaching        sion technique quickly enough and persistently, in
the patient the correct tension technique. However, be-          order to reverse the physiological response.
fore starting with this it is imperative to assess the pa-          Between sessions the patient has the same home-
tient’s blood pressure to get a baseline measure before          work assignment as after the first session, that is, five
tensing and to rule out high blood pressure. Then the            practice occasions of tension–release tension per day.
therapist models the tension technique by sitting in
front of the patient and showing him or her to tense the         3. The Fourth Session
gross body muscles—arms, chest, and legs—and to                     For the fourth session the patient is taken to the hos-
keep tensing for 10 to 15 seconds, or long enough to             pital’s blood donor center in order to provide him or
feel a sensation of warmth rising in the face. Then the          her with a natural situation in which the application of
tension is released and the patient goes back to normal          tension technique can be practiced. To begin the pa-
without attempting to relax. After a pause of 20 to 25           tient is guided around the center by a nurse who also
seconds there is a new tension of 10 to 15 seconds fol-          describes how the blood is managed. Then the patient
lowed by a release and pause. After five cycles of tens-          watches other blood donors donating blood, and finally
ing–releasing the therapist once more assesses the               has a blood sample of his or her own withdrawn. The
patient’s blood pressure, and usually this will indicate         purpose of this is to assess if the patient is suitable to
an increase from baseline with 4 to 5 mmHg of DBP                become a blood donor, since donating blood regularly
and 8 to 10 mmHg of SBP.                                         is one way in which the patient can maintain the skill
   As homework assignment the patient should do five              he or she has acquired during the treatment period.
practice sessions per day, which only takes about 4 min-            One problem that might arise is if the patient has to
utes when it includes five cycles as described above. One         use the tension technique during the venipuncture,
106                                                    Applied Tension

which may make it difficult, or impossible, for the nurse         of muscle tension during an ordinary 3 hour session
to draw blood. The therapist should anticipate this prob-        would lead to quite a lot of muscle soreness. This
lem and teach the patient differential tension, that is, to      would, in turn, make it difficult for the patient to focus
be relaxed in the nondominant arm while at the same              the concentration on what is necessary (i.e., observing
time tensing the dominant arm, the chest, and the legs.          the very first signs of drop in blood pressure).
                                                                    The one-session AT starts with the same rationale as
4. The Fifth Session                                             above. Then follows 15 minutes of tension training with
   For the final session the patient is brought to the de-        the blood pressure assessment before and after to demon-
partment of thoracic surgery at the university hospital          strate to the patient that he or she can increase the blood
where he or she can observe an open-heart or lung sur-           pressure in a nonexposure situation. The application
gery from an observation room one story above the op-            training uses 10 of the 30 slides used for the five-session
erating theater. During this session the patient has             AT, but the procedure is the same as described earlier. If
many opportunities to practice application of the ten-           time permits further exposure to blood-injury stimuli can
sion technique, and the therapist’s primary responsibil-         consist of talking about blood situations, looking at blood
ity is to coach the patient to do so. Should the patient         in a test tube or at a bloody bandage, having a finger
faint, which rarely happens, the therapist will help the         pricked, and so on. The purpose of the application train-
patient to regain consciousness and then use the ten-            ing is the same as for the longer version, that is, for the
sion technique for a while in order to be able to resume         patient to acquire the skill to recognize the drop in blood
exposure to the operating scene as soon as possible.             pressure and to apply the tension technique to reverse
First the patient should be lying on the floor, then sit-         this curve, and abort the reaction altogether. After the
ting on the chair but turned away from the operating             session the patient is giving the same homework assign-
table, and then gradually turning toward it while tens-          ment as in the five-session AT: to practice the tension
ing continuously if necessary.                                   technique five times a day.
                                                                    The outcome of the study indicated that the one-ses-
5. The Maintenance Program                                       sion AT was as effective as the five-session treatment on
   At the end of session 5 the therapist describes the           almost all of the measures. Thus, from a clinical point
maintenance program to the patient. This starts with a re-       of view the brief treatment may be preferable since it
view of the progress that the patient has made so far, and       does not involve taking the patient to a blood donor
then follows a description of what the patient could do in       center or a thoracic surgery department.
the next 6 months in order to maintain, and further, this
improvement. An agreement is made between therapist
and patient that the latter should continue exposing him-                    II. THEORETICAL BASIS
self or herself to blood-injury stimuli at least twice a                     FOR APPLIED TENSION
week. Examples of situations are looking at pictures of
wounded people, watching TV programs of surgical pro-               According to the rationale for AT this coping tech-
cedures, talking to others about such things, watching           nique works because by tensing the large body muscles
others donate blood, and donating blood oneself. The pa-         the patient can stop the blood pressure from falling too
tient has specific forms to fill out and mail to the therapist     low, and then increase it to a normal level for the indi-
once every four weeks. Upon receiving a form the thera-          vidual patient. As a consequence of this the cerebral
pist calls the patient on the phone and talks with him or        blood flow will not decrease below a critical level and
her for 10 to 15 minutes about the experiences of the past       the patient will not faint.
period. The patient also is taught the difference between a         What evidence is there for this explanation? In the
setback and a relapse, and is given a set of instructions on     three randomized clinical trials of AT done at my clinic
what to do in case a setback occurs.                             the patients (N = 40) increased their blood pressure sig-
                                                                 nificantly from the pre- to the post-tensing phase while
                                                                 being continuously exposed to slides of wounded people.
            E. A Brief Version of AT
                                                                 The mean SBP increases were 13.6, 17.0, and 16.2
   In an attempt to investigate whether the five-session          mmHg, and the corresponding means for DBP were 5.8,
version of AT described above could be abbreviated               7.8, and 12.4, respectively. This indicates that blood pho-
into a one-session treatment a study was undertaken in           bic patients can acquire the tension skill after 1 week of
my clinic. The one-session AT was maximized to 2                 practice and use it effectively during the treatment ses-
hours, since pilot cases indicated that the large amount         sions at the clinic. Unfortunately, we have not been able
                                                       Applied Tension                                                107
to assess BP during sessions 4 (blood donor center) and 5        patients with essential hypertension do not react as
(thoracic surgery). Furthermore, our physiological               readily with the drop in blood pressure that is charac-
equipment has not allowed us to assess cerebral blood            teristic of blood-phobic patients.
flow, but other researchers have shown that the tension
technique also leads to an increase in this parameter.
   Another question concerning the mechanism of                             IV. EMPIRICAL STUDIES
change for AT is whether the whole package consisting
of the tension technique and exposure to blood-injury               So far we have completed three clinical trials of AT in
stimuli is necessary to obtain a good result. If this is not     patients with blood-injury phobia. These are summa-
the case, which of the two components is the most im-            rized in Table 1. The conclusion that can be drawn
portant for the treatment effect? In one of our studies          from these studies is that AT is an effective treatment,
AT was compared with tension-only and exposure-only,             which yields better effects than exposure. However, it
and the results showed AT and tension-only to be                 also seems that the application phase is of less impor-
equally effective and more so than exposure-only. In a           tance than acquiring the coping skill; learning the ten-
subsequent study AT for one session and tension-only             sion technique well and having the knowledge of when
for one session were as effective as AT for five session.         and how to use it seem to be the most important factors
Thus the conclusion that can be drawn is that it is the          in AT. Our latest study also indicates that an abbrevi-
coping technique (i.e., learning to tense and when to            ated one-session (2 hours) treatment is as effective as
use it) that is the important component in AT.                   the full 5-hour AT, which is good news to the practicing
                                                                 therapist who may not have easy access to a blood
                                                                 donor center and a thoracic surgery department.

                III. APPLICATIONS
                AND EXCLUSIONS                                               V. CASE ILLUSTRATION

   AT was specifically developed for patients with                  A 24-year-old female patient had suffered from her
blood-injury phobia and it has turned out to be the              blood phobia for 10 years, but never actually fainted in
treatment of choice for this subgroup of specific pho-            the phobic situation since she had always managed to
bia. In DSM-IV injection phobia is included in the same          escape or avoid these situations altogether. She had a
diagnostic category and about 50% of patients with in-           father and a sister who also had blood phobia. When
jection phobia have a history of fainting in their phobic        testing her before treatment her mean baseline values
situations. For these I recommend teaching them the              were SBP 122 and DBP 79 mmHg. During the instruc-
tension technique, but this is not enough; they also             tion phase these values increased to 133 (SBP) and 87
must be exposed to various injections, venipunctures,            (DBP) and at the beginning of the test phase there was
and pricking of fingers so that they acquire the skill of         a large increase to 161 (SBP) and 100 (DBP). This was,
differential tension of the muscles (if necessary) while         however, followed by a dramatic decrease to 94 (SBP)
the nurse carries out these procedures.                          and 54 (DBP), and the patient fainted after watching
   Since very few patients with other anxiety diagnoses          the videotape of thoracic operations for 4 minutes.
have a history of fainting when encountering their pho-          After being unconscious for a brief period (10 to 15
bic stimuli there is very little need for AT in other in-        seconds) the patient’s blood pressure gradually ap-
stances. Patients with panic disorder often experience           proached baseline without quite reaching the initial
dizziness in their panic attacks, but they do not have a         level. After receiving the AT the patient managed to
drop in blood pressure. Whether AT could have a bene-            watch the entire videotape (30 minutes) without any
ficial effect on this subjective feeling of dizziness re-         drop in blood pressure and no fainting behavior what-
quires systematic research. However, there might be a            soever. She did not have to use the tension technique at
risk of increasing the BP too much in patients who have          the posttreatment assessment and when asked about
a normal or elevated BP to start with.                           this she explained that she now felt very confident that
   If a patient has a diagnosed hypertension, temporal           she could cope with a drop in blood pressure, should it
arthritis, or previous stroke one should be cautious             occur. At the 1-year follow-up the improvements were
with the tension training and assess the BP frequently           maintained and during that year the patient had en-
to make sure that the BP does not rise to a level that is        countered a number of blood-phobic situations and
too high. However, it may be the case that blood phobic          coped very well with them. At one occasion she even
108                                                         Applied Tension

                                                           TABLE 1
                                 Clinical Trials of AT in Patients with Blood-Injury Phobia

                                            Treatment         Drop-out                                            Percent       Follow-up
Study                   Treatments          time (hr)   N       (%)             Measures             Results    improvement     (months)

Öst et al. (1989)   1. Applied tension         5        10       0         Behavioral test           1=2=3       1:100, 2:73,       6
                                                                                                                   3:90
                    2. Applied relaxation      9        10       0         A. Rating of fainting     1=2=3       1:100, 2:94,
                                                                                                                   3:89
                    3. Combination 1+2        10        10       0         Self-rating of anxiety    1=2=3       1:56, 2:44,
                                                                                                                   3:89
Öst et al. (1991)   1. Applied tension         5        10       0         Behavioral test           1=3>2       1:100, 2:64,       12
                                                                                                                   3:100
                    2. Exposure in vivo        5         9       0         A. Rating of fainting     1=3>2       1:97, 2:41,
                                                                                                                   3:95
                    3. Tension-only            5         9       0         Self-rating of anxiety    1=2=3       1:54, 2:48,
                                                                                                                   3:37
Hellström et al.    1. Applied tension:        5        10       0         Behavioral test           1=2=3       1:88, 2:100,       12
  (1996)               spaced                                                                                      3:100
                    2. Applied tension:        1        10       0         A. Rating of fainting     1=2=3       1:71, 2:78,
                       massed                                                                                      3:71
                    3. Tension-only:           1        10       0         Self-rating of anxiety    1=2=3       1:58, 2:67,
                       massed                                                                                      3:57




assisted at the scene of a traffic accident without expe-                 treatment for blood phobia and the effects are main-
riencing any fainting sensations.                                        tained at follow-up 1 year later.


                                                                                See Also the Following Articles
                    VI. SUMMARY
                                                                         Anxiety Management Training      I    Applied Relaxation
   Applied tension is a coping method specifically devel-
oped for the treatment of blood-injury phobia (and to                                        Further Reading
some extent injection phobia). This method specifically
focuses on the original physiological responses, which                   Hellström, K., Fellenius, J., & Öst, L-G. (1996). One vs. five
                                                                           sessions of applied tension in the treatment of blood pho-
are characteristic of blood phobia: the diphasic pattern
                                                                           bia. Behaviour Research and Therapy, 34, 101–112.
with an initial increase and then a rapid decrease in                    Öst, L-G. (1992). Blood and injection phobia: Background,
blood pressure. The first step of AT consists of teaching                   cognitive, physiological, and behavioral variables. Journal
the patient an effective tension technique, which leads to                 of Abnormal Psychology, 101, 68–74.
an increase in blood pressure. The patient is taught to                  Öst, L-G., Fellenius, J., & Sterner, U. (1991). Applied tension,
tense the arms, the chest, and the leg muscles, and by as-                 exposure in-vivo, and tension-only in the treatment of blood
sessing the patient’s blood pressure the therapist can                     phobia. Behaviour Research and Therapy, 29, 561–574.
demonstrate that the tension really increases blood pres-                Öst, L-G., & Sterner, U. (1987). Applied tension. A specific
                                                                           behavioral method for treatment of blood phobia. Behav-
sure. The second step is to expose the patient to various
                                                                           iour Research and Therapy, 25, 25–29.
blood-injury stimuli (slides of wounded people, blood
                                                                         Öst, L-G., Sterner, U., & Fellenius, J. (1989). Applied tension,
donation, and thoracic surgery) so that he or she can                      applied relaxation, and the combination in treatment of
practice applying the tension as soon as the very first                     blood phobia. Behaviour Research and Therapy, 27, 109–121.
signs of a drop in blood pressure, are experienced. Ran-                 Page, A. C. (1994). Blood-injury phobia. Clinical Psychology
domized controlled trials show that AT is an effective                     Review, 14, 443–461.
                                       Arousal Training
                                                    Marita P. McCabe
                                               Deakin University, Burwood, Australia




    I.   Description of Treatment                                       females. These two conditions have been selected be-
   II.   Theoretical Bases                                              cause (1) there is a reasonable body of literature that re-
  III.   Empirical Studies                                              lates to the use of arousal training with these
  IV.    Summary                                                        conditions; and (2) the treatment of enuresis involves
         Further Reading
                                                                        training the individual to lower arousal levels, whereas
                                                                        the treatment of inorgasmia involves training to in-
                                                                        crease arousal levels.
                            GLOSSARY                                       Arousal training among children with enuresis gen-
                                                                        erally involves teaching the child to use a waking de-
classical conditioning The main feature of this form of condi-
                                                                        vice to prevent them from wetting the bed. Parental
   tioning is that the originally neutral conditioned stimulus,
   through repeated pairing with the unconditioned stimulus,            involvement is an important aspect of therapy. The
   acquires the responses originally given to the uncondi-              focus of the therapy is on teaching the child the physi-
   tioned stimulus.                                                     ological sensations that precede nocturnal enuresis
operant conditioning This type of conditioning involves the             (i.e., their arousal levels), so that he or she wakes and
   strengthening of an operant response by presenting a rein-           goes to the bathroom to urinate rather than wetting the
   forcing stimulus if the response occurs.                             bed. Thus, the focus of the training is on increasing the
                                                                        percentage of dry nights rather than on eliminating
                                                                        bed-wetting.
                                                                           This technique uses a signal alarm device. When the
         I. DESCRIPTION OF TREATMENT                                    child wets the bed, a moisture-sensing device near the
                                                                        genitals is activated and triggers an alarm. This alarm
   Arousal training is a technique that is used in the                  can either be a sound or a vibrating device. Both mech-
treatment of a number of clinical conditions. The es-                   anisms have been found to be effective in waking chil-
sential aspect of the treatment involves training indi-                 dren. Only a couple of drops of urine are necessary to
viduals to detect their levels of arousal, which are then               trigger the alarm. Through this process the child grad-
the focus of treatment. Patients are trained either to                  ually learns the physiological sensations associated
further enhance arousal levels or to reduce levels of                   with a full bladder and wakes to urinate in the bath-
arousal, depending on what is required for a successful                 room without the sound of the alarm.
outcome.                                                                   Reward systems are very important for this training to
   This article focuses on two quite different conditions               work (e.g., rewards for dry nights). Both the parents and
that utilize arousal training: enuresis and inorgasmia in               child must be highly motivated. Involvement in training


Encyclopedia of Psychotherapy                                                                       Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                          109                                                   All rights reserved.
110                                                  Arousal Training

entails recording the child’s responses to the alarm and           Clearly, more research needs to be conducted on the
monitoring his or her progress. The success rate for ther-      most useful treatment strategy to increase female sex-
apy is in the 92% range, but the course of therapy can be       ual arousal. It would appear that arousal training is ef-
two or three months. Reward systems need to remain in           fective in the treatment of subjective sexual arousal,
place for at least three weeks after complete dryness has       but the specific elements to include in this training
been achieved. Relapse rates are higher if the alarm sys-       process still need to be clarified. Enhancement of phys-
tem is removed after shorter dry periods.                       iological sexual arousal among women has been largely
   Arousal training for inorgasmia among women in-              neglected. Research needs to focus on the elements that
volves utilizing mechanisms that enhance sexual                 are most useful in arousal training programs to im-
arousal. Women with inorgasmia generally demon-                 prove the physiological levels of arousal, and also on
strate low levels of arousal, so therapy needs to focus         the relationship between physiological and subjective
on mechanisms designed to increase arousal levels. The          arousal in the treatment of inorgasmia.
focus of this arousal training needs to be directed to-
ward both subjective and physiological levels of
arousal. In an excellent 1995 review of the literature,                    II. THEORETICAL BASES
Laan and Everaerd demonstrated how research studies
have indicated the independence of these two dimen-                Enuresis may have either an organic or a psychologi-
sions of arousal, particularly among women. Thus,               cal etiology. This discussion focuses on the psychologi-
arousal training needs to focus on mechanisms that              cal explanation for development of the disorder and on
will enhance both aspects of arousal.                           the reason for the effectiveness of arousal training in its
   The most commonly used measure of physiological              treatment. It has been proposed that the waking alarm
sexual arousal among women is vaginal vasoconges-               described earlier works through classical conditioning.
tion. This is generally achieved by using a vaginal pho-        Repeated pairings occur between the sensation of a full
toplethysmograph which measures both vaginal blood              bladder, the child wetting the bed, the sound of the
volume and vaginal pulse amplitude, with vaginal                alarm, and the child waking up. In time, the child
pulse amplitude generally being seen as the most accu-          learns to wake to the sensation of a full bladder prior to
rate measure of sexual arousal. Strategies to increase          wetting the bed. Thus, the training is focused on the
physiological levels of sexual arousal include measures         eventual association between a full bladder and waking
to reduce anxiety and sexual threats and also increasing        up. Arousal training for enuresis also utilizes operant
the salience of the sexual stimulus. Although there is          conditioning. Children may perceive the sound of the
some speculation about the factors that need to be ad-          alarm, waking in the night, and cleaning up as an aver-
dressed to increase sexual arousal, the exact mecha-            sive condition, and so may learn to avoid this situation
nism whereby this is achieved has not been developed            by learning to keep dry.
or evaluated. Subjective sexual arousal generally in-              Both of these behavioral approaches use the theoret-
volves an assessment of the woman’s subjective evalua-          ical underpinning of conditioning to increase the
tion of her arousal levels on a rating scale.                   child’s self-control of nocturnal bed-wetting behaviors.
   Sexual arousal in women has been shown to be en-             The basic assumption behind this approach is that lack
hanced using arousal training. Marita McCabe and her            of bladder control is a learned response. Arousal train-
colleague have suggested that training focus on both            ing, using either classical or operant conditioning, is
response imagery (that is, sexual fantasy which relates         designed to reverse change these behaviors.
to the woman’s own sexual responses) and stimulus                  Inorgasmia is viewed as being due to low physiologi-
imagery (that is, sexual fantasy which relates to sexu-         cal levels of arousal or perceived low levels of arousal
ally stimulating situations), as well as relaxation. Thus,      for the subjective dimension, and arousal training is
arousal training needs to focus on both a woman’s re-           needed to alter this situation. Imagery training, which
sponses to sexual fantasy and her generation of sexu-           focuses on both stimulus and response imagery, is used
ally stimulating scripts in order to effectively increase       to increase arousal levels. Consistent with proposals re-
her levels of subjective sexual arousal. They also sug-         garding imagery training among inorgasmic women, it
gested that arousal training should focus on strategies         would appear that reinforcement of appropriately re-
to decrease performance concerns, since levels of per-          called stimulus or response imagery during imagery
formance anxiety were inversely related to subjective           training is an essential ingredient in the treatment of
sexual arousal.                                                 inorgasmia. Thus, operant conditioning would seem to
                                                      Arousal Training                                                111
be an appropriate theoretical position to explain the ef-        and most of these relapses were treated successfully by
fectiveness of arousal training with this disorder. Such         parents reinstituting arousal training techniques (60%),
an explanation is consistent with other approaches               without seeking professional help.
used to explain the treatment of inorgasmia.                        In contrast to these results, Walling only reported a
   Sexual arousal has been conceptualized as an emo-             success rate of 70% using an alarm. However, Walling’s
tion, which results from the interaction between cogni-          paper does not make clear if the respondents were
tive processes and physiological response systems.               drawn from a clinical population and if all aspects of
Therefore, in order to experience subjective sexual              arousal training (reinforcement as well as the alarm)
arousal, individuals need to be able to accurately detect        were used in treatment. Schulman, Colish, von Zuben,
these bodily sensations. There appear to be substantial          and Kodman-Jones also found a success rate of 56%
individual differences in the awareness of basic bodily          using an alarm in the treatment of their clinical patients
sensations, which are related to genital responsiveness,         with enuresis. However, this rate was significantly bet-
perception thresholds, and attentional focus. A stimu-           ter than the use of medication (18% and 16% for two
lus may convey different meanings, depending on the              different medical interventions).
learning experiences of the individual (i.e., the individ-          In reviews of studies to treat nocturnal bed-wetting,
ual’s history), and so the interpretation placed on the          it was found that the most effective treatment for
current circumstances.                                           enuresis was dry bed training and an enuresis alarm.
   It has been argued that people learn to be sexual. For        The data also demonstrated that success was more
women, this learning process involves tuning into a              likely when the problem was maturational and less
wide range of situational and physiological cues. Ap-            likely in situations where there was a psychiatric disor-
praisal of the current situation (based on prior learning        der of the child, severe family stress, lack of concern by
experiences), in combination with feedback from geni-            child and parents, or urological dysfunction. Medica-
tal sensations, combines to lead to subjective sexual            tion was shown to have limited usefulness and was ef-
arousal in women. Thus, arousal training to treat inor-          fective primarily when there was a physiological cause
gasmia needs to reverse this learning process by dealing         for the enuresis.
with feedback from both the interpretation of the situa-            Other researchers have reported up to 90% effective-
tion and genital responses.                                      ness with a short-term conditioning techniques for
                                                                 enuresis. However, closer examination of these tech-
                                                                 niques demonstrates that they involved the use of an
           III. EMPIRICAL STUDIES                                alarm, but this was not accompanied by reinforcement
                                                                 from the parents for dry nights. Within this literature
   Arousal training has been shown to be extremely ef-           there are major difficulties in comparing results across
fective in the treatment of enuresis, provided it is main-       different studies. The severity of the children’s enuresis,
tained for a sufficient period of time, and implemented           the level of support provided by the parents, the num-
appropriately by parents. Clearly, if the enuresis is due        ber of treatment sessions, as well as the focus of the
to a physiological condition, the problem needs to be            treatment program, all show substantial variability
treated using appropriate medication. These medica-              across studies. These factors will undoubtedly impact
tions, and their effectiveness, will not be considered in        on the effectiveness of the arousal training procedure.
this chapter, for this discussion focuses primarily on the          It appears that arousal training in its various forms is
treatment of enuresis due to a psychological etiology.           the most effective treatment for enuresis. This is most
   Van Londen and colleagues demonstrated that arousal           likely to be successful if both the child and the parents
training obtained a 98% success rate with nonclinical            are highly motivated, and the therapist acts to clearly
boys and girls with nocturnal enuresis between the ages          communicate the strategies to be employed and assists
of 6 and 12 years. Even 21/2 years after the initial train-      in the maintenance of motivational levels within the
ing, 92% of children were continent. This compared               family.
with a success rate of 84% where reward reinforcement               A number of studies have evaluated the effectiveness
only was used, and 73 percent where the urine alarm              of arousal training in the treatment of inorgasmia in
was used without any rewards. The 21/2 year success rate         women. In a review of studies that examined the factors
for these two approaches was 77% and 72%, respectively.          that contributed to sexual arousal among women, it was
The majority of children in the arousal training condi-          found that masturbation frequency, coital frequency, and
tion who experienced a relapse did so only once (62%),           having a positive opinion about erotic stimulus and a
112                                                   Arousal Training

higher awareness of vaginal lubrication were the most            for a number of weeks after the child has a dry bed in
significant predictors of both subjective and physiologi-         order to firmly establish the new learning processes.
cal sexual arousal. These results would suggest that re-            Arousal training also appears to be effective in the
spondents who have a positive attitude to their sexual           treatment of inorgasmia in women. Learning theory
responses, and who are attuned to their levels of arousal,       can be used to explain the development of this sexual
are more likely to experience higher levels of both phys-        dysfunction, and inorgasmic women have been shown
iological and subjective sexual arousal. Thus, arousal           to experience low levels of sexual arousal. Although
training would be expected to be an effective therapy            further research is needed to determine other strategies
with women experiencing inorgasmia.                              to enhance arousal, preliminary research would suggest
   This prediction is supported by studies by McCabe             that imagery training is an effective mechanism to in-
and her colleagues that employed imagery training to             crease arousal levels.
enhance sexual arousal among inorgasmic. Imagery                    Further research needs to be conducted to determine
training was used in both of these studies to desenzitize        the effectiveness of arousal training with other clinical
inorgasmic women to the anxiety and fears that they              disorders.
held regarding sexual arousal and orgasmic respond-
ing. This process of desentitization was designed to en-
hance both physiological arousal and subjective levels
                                                                         See Also the Following Articles
of arousal. It was, therefore, a form of arousal training        Bell-and-Pad Conditioning I Classical Conditioning I
that was designed to operate at both the physiological           Nocturnal Enuresis I Operant Conditioning I Orgasmic
and subjective level. The data from both studies                 Reconditioning I Sex Therapy
demonstrated some level of effectiveness using these
techniques.                                                                         Further Reading
   A problem with using arousal training among women
                                                                                                 .
                                                                 Delany, S. M., & McCabe, M. P (1988). Secondary inorgasmia
who experience inorgasmia is that there may be habitu-
                                                                    in women: A treatment program and case study. Sexual and
ation to stimuli. As yet, there appear to be no clear data          Marital Therapy, 3, 165–190.
on the circumstances under which habituation occur,              Everaerd, W., & Laan, E. (1995). Desire for passion: Energet-
and some sexual stimuli continue to retain their sexual-            ics of sexual response. Journal of Sex and Marital Therapy,
arousing capacities despite repeated exposure.                      21, 253–261.
   Further studies need to be conducted on arousal                          .,
                                                                 Friman, P & Volmer, D. (1995). Successful use of the noc-
training for inorgasmia, and the effectiveness of the               turnal alarm for diurnal enuresis. Journal of Applied Behav-
treatment programs needs to be contrasted with both                 ioral Analysis, 28, 89–90.
alternative treatment programs that do not utilize               Gimpel, G. A., & Warzak, W. J. (1998). Clinical perspectives in
arousal training strategies and wait-list controls. Al-             primary nocturnal enuresis. Clinical Paediatrics, 37, 23–30.
though theoretically one would expect arousal training           Houts, A. C., Berman, J. S., & Abramson, H. (1994). Effec-
                                                                    tiveness of psychological and pharmacological treatments
to be a useful approach for the treatment of inorgasmia,
                                                                    for nocturnal enuresis. Journal of Consulting and Clinical
until these studies are completed it is difficult to draw            Psychology, 62, 737–745.
any confident conclusions about the effectiveness of              Laan, E., & Everaerd, W. (1995). Determinants of female sex-
this type of therapy among inorgasmic women.                        ual arousal: Psychophysiolical theory and data. Annual Re-
                                                                    view of Sex Research, 6, 32–76.
                                                                 Levin, R. (1992). The mechanism of human female sexual
                   IV. SUMMARY                                      arousal. Annual Review of Sex Research, 3, 1–48.
                                                                 Marcovitch, H. (1993). Treating bedwetting: Bladder exer-
   Arousal training is a therapeutic technique that uses            cises, star charts, enuresis alarms, and now ERIC. British
learning principles to either decrease or increase levels           Medical Journal, 306, 536–537.
of arousal in order to achieve an appropriate therapeu-                                        .
                                                                 Purcell, C., & McCabe, M. P (1992). The impact of imagery
                                                                    type and imagery training on the subjective sexual arousal
tic outcome.
                                                                    of women. Sexual and Marital Therapy, 7, 251–260.
   This approach has been used effectively in the treat-                                                     .
                                                                 Schulman, S. L., Colish, Y., von Zubin, F C., & Kodman-
ment of nocturnal enuresis among children. Interven-                Jones, C. (2000). Effectiveness of treatments for Nocturnal
tions are most likely to be effective if both the child and         Enuresis in a heterogeneous population. Clinical Paedi-
the parent are highly motivated, and if the arousal alarm           atrics, 39, 359–367.
in combination with reinforcement is used in the treat-          Walling, A. D. (1999). Nocturnal enuresis. American Family
ment regime. It is also important to continue treatment             Physician, 60, 644.
                                                Art Therapy
                                              Marcia Sue Cohen-Liebman
                   Philadelphia Children’s Alliance, MCP Hahnemann University, and American Art Therapy Association




    I.   Definition                                                       interests, concerns, and conflicts. Art therapy practice
   II.   Background                                                      is based on knowledge of human developmental and
 III.    Theoretical Constructs                                          psychological theories, which are implemented in the
  IV.    Materials/Media                                                 full spectrum of models of assessment and treatment.
   V.    Artistic Developmental levels
                                                                            Art therapy is an effective treatment for the develop-
  VI.    The Art Therapist
                                                                         mentally, medically, educationally, socially, or psycho-
 VII.    Educational Requirements
VIII.    Art Therapy Credentials Board
                                                                         logically impaired. It is practiced in mental health,
  IX.    American Art Therapy Association                                rehabilitations, medical, educational, and forensic in-
         Further Reading                                                 stitutions. Populations of all ages, races, and ethnic
                                                                         backgrounds are served by art therapists who provide
                                                                         services to individuals, couples, families, and groups.


                            GLOSSARY                                                     II. BACKGROUND
art therapy A human service profession that utilizes art
   media, images, the creative process, and patient/client re-              Art therapy emerged as a distinct profession in the
   sponses to art productions as reflections of an individual’s           1930s. Since that time art therapy has grown into an ef-
   development, abilities, personality, interests, concerns, and         fective and important method of communication, as-
   conflicts.                                                             sessment, and treatment. Sound theoretical principles
American Art Therapy Association (AATA) A 5000-member                    and therapeutic practices govern the modality. The the-
   association founded in 1969 that is governed and directed             oretical orientation of art therapy includes psychoana-
   by a nine-member board elected by the membership.                     lytic theory as well as art education.


                         I. DEFINITION
                                                                              III. THEORETICAL CONSTRUCTS
   Art therapy is a human service profession that uti-
lizes art media, images, the creative process, and pa-                      Two schools of thought are fundamental to the pro-
tient/client responses to art productions as reflections                  fession of art therapy: Art Psychotherapy and Art as
of an individual’s development, abilities, personality,                  Therapy. Both have contributed to the progressive de-



Encyclopedia of Psychotherapy                                                                       Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                           113                                                  All rights reserved.
114                                                      Art Therapy

velopment of the field. Often basic tenets associated             media as well as what may be evoked by the introduc-
with both schools of thought are integrated in the prac-         tion of certain materials. The art therapist assesses the
tice of art therapy. Psychoanalytic tenets provide the           stimulus potential of the media in conjunction with the
basis for both methods of practice.                              coping skills of the client/patient in an effort to intro-
   Margaret Naumburg is credited with the first use of            duce appropriate materials and tasks. The art therapist
art expression as a therapeutic modality. She encour-            is trained to comprehend what is being expressed with
aged her patients to draw spontaneously and to free as-          regard to the media. Different media evoke different re-
sociate to their drawings in the 1940s. Her use of art           sponses and convey different messages.
was based on psychoanalytic theory and practice. She                Art materials exist on a continuum from structured
believed that art therapy was dynamically oriented and           to unstructured. Structured media have a definitive
was dependent on the transference relationship be-               shape and form and make a definitive mark. Two-di-
tween patient and therapist. For Naumburg therapeutic            mensional art materials are representative of structured
art expression allows for a symbolic communication,              media, including pencils, crayons, markers, and pas-
which bypasses difficulties encountered with verbal               tels. Unstructured media, such as clay or paint, require
communication. Naumburg encouraged the patient to                the user to give the media shape and form. It does not
discover for himself or herself the meaning of his or her        make a consistent line and is more subject to gravity.
artwork. Art psychotherapy is a process-oriented ap-             The art therapist’s capability to comprehend and inter-
proach that involves art behavior, clinical behavior, and        pret what is being expressed with regard to the media is
the associations of the patient. The latter is fundamen-         fundamental to the practice of the modality. This infor-
tal to comprehending a client or patient’s understand-           mation provides the art therapist with insight regarding
ing of his or her imagery.                                       underlying issues, conflicts, and concerns.
   In contrast, Edith Kramer concentrated on the inte-
grating and healing properties of the creative process it-
self. Her theories evolved out of her work with children
in the 1950s. For Kramer the healing quality inherent in
                                                                        V. ARTISTIC DEVELOPMENTAL
the creative process explains the usefulness of art in ther-
                                                                                   LEVELS
apy. In art as therapy, the therapist functions as an auxil-
iary ego and assumes a supportive role. Sublimation is a            A phase-specific developmental sequence has been as-
key component associated with Kramer’s work. Judy                sociated with children’s drawings. Although different
                                                                 phases or stages have been identified by different re-
Rubin in 1984 explained that in the creative act (art mak-
                                                                 searchers, children’s artistic development is sequential
ing), conflict is reexperienced, resolved, and integrated.
                                                                 and contingent on mastery of skills. Knowledge of typi-
   For Naumburg, art making assisted the therapeutic
                                                                 cal developmental variants is essential to understanding
process. Kramer focused on the art making believing
                                                                 the graphic productions created by children. Many fac-
that the creative process in and of itself was intrinsi-
                                                                 tors and influences will contribute to maturation in de-
cally therapeutic.
                                                                 velopmental spheres including artistic. Cathy Malchiodi
   Myra Levick in 1983 recognized the correlation be-
                                                                 in 1998 explored developmental aspects of children’s
tween emotional development, intellectual develop-
                                                                 drawings in her text, Understanding Children’s Drawings.
ment, and creative expression that is fundamental to art
therapy. Levick also developed criteria for the identifi-
cation of defense mechanisms of the ego in graphic
productions. This knowledge assists with the identifi-                       VI. THE ART THERAPIST
cation of areas of fixation as well as conflicts and issues
that are central to the individual.                                 Art therapists are skilled in the therapeutic use of art.
                                                                 Art therapists use their backgrounds as artists and their
                                                                 knowledge of art materials in conjunction with clinical
            IV. MATERIALS/MEDIA                                  skills. The art therapist treats clients/patients through
                                                                 the use of therapeutic art tasks. While the art therapy
  Media is a term used to describe art materials. Media          process uses art making as a means of nonverbal com-
encompass a variety of items including two- and three-           munication and expression, the art therapist makes use
dimensional materials. An art therapist is familiar with         of verbal explorations and interventions. Art therapists
the inherent properties and resulting qualities of the           do not own art or the healing that comes from its use.
                                                        Art Therapy                                                           115
The therapeutic use of art distinguishes the art therapist        The Mission statement of the American Art Therapy
from other helping professions. The art therapist may act       Association is as follows:
as a primary therapist or as an adjunct within the treat-
ment team, depending on the needs of the institution                      The American Art Therapy Association, Inc. (AATA)
and the treatment objectives of the patient. Art therapists           is an organization of professionals dedicated to the belief
function in many capacities including supervisors, ad-                that the creative process involved in the making of art is
ministrators, consultants, and expert witnesses.                      healing and life enhancing. Its mission is to serve its
                                                                      members and the general public by providing standards
                                                                      of professional competence, and developing and pro-
                                                                      moting knowledge in, and of, the field of art therapy.
               VII. EDUCATIONAL
                REQUIREMENTS                                       Conceptually, AATA’s philosophy, goals, and objec-
                                                                tives endeavor to ensure credentialed art therapists de-
   Professional qualification for entry into the field re-        liver the highest standard of care possible to the general
quires a master’s degree from an accredited academic in-        public. AATA’s mission fosters the highest level of qual-
stitution or a certificate of completion from an accredited      ity services from professional, highly trained art thera-
institute or clinical program. Specialized training pro-        pists. AATA’s vision for the 21st century is the
grams include didactic instruction and practicum expe-          inculcation and recognition of art therapy as an integral
rience. Graduate art therapy training programs are              part of all health care delivery systems.
commonly associated with medical colleges or universi-             For more information regarding the profession of art
ties. The designation art therapist registered, ATR, is         therapy and the National Association contact: The Amer-
granted to individuals who have successfully completed          ican Art Therapy Association, Inc. (AATA), www.artther-
the required educational and professional experience.           apy.org. For more information regarding registration and
                                                                certification contact: The Art Therapy Credentials Board,
                                                                Inc. (ATCB), atcb@nbcc.org.
              VIII. ART THERAPY                                    Resources available from AATA include professional
             CREDENTIALS BOARD                                  preparation literature as well as art therapy literature.
                                                                Sample brochures include: Art Therapy the Profession,
   The Art Therapy Credentials Board, Inc. (ATCB), an           Art Therapist Model Job Description, Fact Sheet, Member-
independent organization, grants postgraduate registra-         ship Survey, Ethical Considerations Regarding The Thera-
tion (ATR) after reviewing documentation of completion          peutic Use Of Art By Disciplines Outside The Field Of Art
of graduate education and postgraduate supervised ex-           Therapy, Art Therapy in the Schools, Educational Pro-
perience. The Registered Art Therapist who successfully         grams, and Ethics Document.
completes the written examination administered by the
ATCB is qualified as Board Certified (ATR-BC), a creden-
                                                                                     Acknowledgment
tial requiring maintenance through continuing educa-
tion credits.                                                     Some material reprinted with permission from the Ameri-
                                                                can Art Therapy Association Inc. All rights reserved.

             IX. AMERICAN ART                                             See Also the Following Articles
           THERAPY ASSOCIATION
                                                                Alternatives to Psychotherapy I Biblical Behavior
   The American Art Therapy Association (AATA) was              Modification I Cinema and Psychotherapy I Therapeutic
                                                                Storytelling with Children and Adolescents
established in 1969 as a nonprofit organization. AATA
is governed and directed by a nine-member board that
is elected by the membership. Current membership is                                   Further Reading
approximately 5000 members in five membership cat-
                                                                                        .
                                                                Junge, M., & Asawa, P (1994). A history of art therapy in the
egories. Affiliate chapters exist throughout the coun-            United States. Mundelein, IL: The American Art Therapy
try and promote the field of art therapy at the local             Asociation, Inc.
level. Educational, professional, and ethical standards         Levick, M. (1983). They could not talk and so they drew: Chil-
for art therapists are regulated by the American Art              dren’s styles of coping and thinking. Springfield, IL: Charles
Therapy Association.                                              C. Thomas.
116                                                         Art Therapy

Levick, M. (1998). See what I’m saying: What children tell us       Naumburg, M. (1987). Dynamically oriented art therapy: Its prin-
  through their art. Dubuque, IA: Islewest Publishing.                ciples and practices. Chicago, IL: Magnolia Street Publishers.
Lowenfeld, V., & Brittain, W. L. (1987). Creative and mental        Olivera, B. (1997 Winter). Responding to other disciplines
  growth. New York: Macmillan.                                        using art in therapy. AATA Newsletter, XXX, 17.
Malchiodi, C. (1998). The art therapy sourcebook. Los Ange-         Rubin, J. (1984). Child art therapy. New York: Van Nostrand
  les, CA: Lowell House.                                              Reinhold.
Malchiodi, C. (1998). Understanding children’s drawings. New        Rubin, J. (1999). Art therapy: An introduction. Philadelphia,
  York: Guilford Press.                                               PA: Brunner/Mazel.
Moon, B. (2000). Ethical issues in art therapy. Springfield, IL:     Wadeson, H. (1980). Art psychotherapy. New York: John
  Charles C Thomas.                                                   Wiley & Sons.
                                       Assertion Training
                                                       Eileen Gambrill
                                                  University of California at Berkeley




    I.   Description of Treatment                                            The aim of assertion training is to enhance interper-
   II.   Theoretical Bases                                                sonal effectiveness in social situations. Positive conse-
  III.   Applications and Exclusions                                      quences may be forgone because of anxiety in social
  IV.    Empirical Studies                                                situations. Assertion training emphasizes the extent to
   V.    Case Example                                                     which we can influence our social environment by
  VI.    Summary
                                                                          being active in its construction. In 1973 Joseph Wolpe
         Further Reading
                                                                          defined assertive behavior as “The proper expression of
                                                                          any emotion other than anxiety toward another per-
                                                                          son.” Lack of effective social skills may result in a vari-
                            GLOSSARY                                      ety of maladaptive behaviors. Assertion training often
                                                                          in combination with other methods, has been used to
behavior rehearsal Practicing behaviors of interest.
                                                                          address a wide variety of presenting complaints includ-
coaching Providing corrective feedback to develop a skill.
cognitive restructuring Helping clients to increase self-state-
                                                                          ing substance abuse, aggressive and explosive behav-
   ments that contribute to attaining valued outcomes and to              iors, and obsessive–compulsive behaviors. It has been
   decrease self-statements that have the opposite effect.                used to help people make friends, arrange dates, and
discrimination training Reinforcing a behavior in one situa-              acquire needed help (e.g., on the part of individuals
   tion and not in others in order to increase the rate of a be-          with learning disabilities). Essentially, assertive skills
   havior in situations in which it will be reinforced (followed          are effective social influence skills acquired through
   by positive consequences or avoidance or decrease of neg-              learning.
   ative consequences).                                                      The terms “assertive behavior” and “assertion” (or
exposure Being in the presence of certain stimuli.                        “assertiveness”) training have been replaced by the
generalization The occurrence of a behavior in situations                 terms “effective/competent social behavior” and “social
   similar to the one in which it was established.                        skills training.” Some authors use the term “assertive be-
hierarchy A ranked order of items such as situations ranked
                                                                          havior” to refer to a circumscribed set of behaviors such
   in relation to degree of anxiety they create.
                                                                          as refusing requests. One problem with use of the term
maintenance The continuation of a behavior over time.
model presentation Presenting exemplars of behavior that
                                                                          “assertive behavior” is confusion of “assertion” with “ag-
   observers can imitate.                                                 gression.” Another potential disadvantage is encourag-
self-management Setting goals and arranging cues and con-                 ing a trait approach to social behavior that obscures the
   sequences to attain certain goals.                                     situational specificity of social behavior; that is, a client
stimulus control Procedure for altering the rate of behavior in a         may be appropriately asertive in some situations (ef-
   situation by rearranging antecedents to behaviors of interest.         fective in achieving desired outcomes such as arranging


Encyclopedia of Psychotherapy                                                                          Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                            117                                                    All rights reserved.
118                                                   Assertion Training

future meetings with a friend), passive in other (e.g., re-       he or she should do) may reveal that the client has
fusing favors), and aggressive in others (e.g., requesting        many effective components of needed skills, and it may
changes in behavior). Assertion training differs from so-         be decided that instructions and prompts during re-
cial skills training in emphasizing individual rights and         hearsal will be sufficient to develop and refine needed
obligations. For example, an advantage of the phrase              skills. If effective behaviors are not used because of
“assertive behavior” for some groups such as women is             anxiety, intervention may focus on enhancing anxiety
an emphasis on taking the initiative to enhance social            management skills. However, if needed social skills are
and other opportunities. There is an activist stance. If          absent, procedures designed to develop them, such as
intervention is successful, anxiety in interpersonal situ-        instructions, model presentation, and practice, may be
ations decreases and assertive responses are used when            needed. Discrimination training is required when skills
a client believes these would be of value in attaining            are available but are not used in situations in which
personal and social goals; clients may be indifferent to          they would result in valued outcomes. This is designed
situations that previously caused discomfort, such as             to increase a behavior in situations in which it will be
minor digs and slights, and misconceptions of situa-              followed by positive outcomes and/or decrease it in sit-
tions as rejecting (perhaps due to oversensitivity)               uations in which negative outcomes are likely. Assess-
should decrease. Discussion of the limiting effects of            ment may reveal that effective behaviors simply have to
stereotyping and role expectations may result in greater          be placed under new stimulus control (i.e., prompted,
sensitivity to certain situations (such as belittling sexist      perhaps by self-instructions, in certain situations). For
remarks) and greater likelihood of assertive reactions in         example, effective ways of requesting favors from a
such situations.                                                  friend may be of value in work situations but not be
                                                                  used there. Training may be carried out individually or
                                                                  in a group setting. A session may focus on developing
      I. DESCRIPTION OF TREATMENT                                 effective behavior in one situation or on increasing a
                                                                  specific behavior of value in a range of similar situa-
   Assertion training usually consists of a variety of            tions (friendly reactions such as smiling).
components, including instruction, model presenta-
tion, behavior rehearsal, feedback, programming of
change, and homework assignments. Other procedures
                                                                                    A. Instructions
that may also be used, depending on what is found dur-               Instructions concerning effective behavior may be
ing assessment, include self-instruction training, relax-         given verbally or presented in written, audiotape, or
ation training, cognitive restructuring (e.g., decreasing         filmed form. This is often combined with model pres-
unrealistic expectations or beliefs), and interpersonal           entation and coaching during role-plays. Specific be-
problem-solving training (helping clients to effectively          haviors are identified to increase, decrease, stabilize, or
handle challenging situations that arise in social situa-         vary and their relationship to desired goals described.
tions such as reactions of anger that get in the way of           Instructions may be given concerning only one behav-
maintaining friendships). Written material may be used            ior at a time, which is then role-played, or more than
to provide instructions and to clarify differences among          one behavior may be reviewed depending on the avail-
aggressive, assertive, and passive behaviors in a situa-          able skills (entering repertoires) of each client. What
tion. For example if you believe you have been treated            not to do (e.g., smile or giggle while requesting a
unfairly by a professor, you could appropriately speak            change in an annoying behavior) as well as what to do
to your instructor about your concerns (be assertive),            (e.g., look at the person, face the person) are described.
say nothing (be passive), or yell at the instructor (be
aggressive). Selection of intervention methods should
flow directly from assessment. This provides informa-
                                                                               B. Model Presentation
tion about the nature of a client’s current cognitive                Instruction, model presentation, rehearsal, and
(what they say to themselves), emotional (what they               coaching can be used when clients lack requisite be-
feel), and behavioral (what they do) repertoires in rela-         haviors in certain situations or when there is a need to
tion to desired goals and related situations, as well as          refine behaviors. The need to use modeling will be in-
likely consequences of and options for rearranging the            fluenced by the complexity of the skill to be acquired
environment. Role-playing during assessment (acting               and nature of the entering repertoires (available skills)
out what is usually done as well as what a client thinks          of clients. The greater the complexity of the skill and
                                                   Assertion Training                                               119
the more lacking the initial repertoire, the greater the       Specific positive aspects of the client’s performance are
value of model presentation is likely to be. An advan-         first noted and praised. Praise is offered for effective be-
tage of model presentation is that an entire chain of be-      haviors or approximations to them, and coaching pro-
havior can be illustrated and the client then requested        vided as needed. The focus is on improvements over
to imitate it. Nonverbal as well as verbal behaviors can       baseline levels (what a client can do before intervention
be demonstrated and the client’s attention drawn to            is initiated). Thus, approximations to hoped-for out-
those that are especially important. For example, a            comes are reinforced. Critical comments such as “You
client can be asked to notice the model’s eye contact,         can do better” or “That wasn’t too good,” are avoided.
hand motions, and posture. Models of both effective            The client is encouraged to develop behaviors that are
and ineffective behavior may be presented. The model           most likely to result in positive consequences. A hierar-
may verbalize (say aloud) helpful positive thoughts            chy of scenes graduated in accord with the client’s anx-
during role plays if effective social skills are hampered      iety may be used for role-playing. Role-playing starts
by negative thoughts such as “I’ll always be a failure,”       with scenes that create low levels of discomfort. Clients
“I’ll never succeed.” At first, appropriate self-state-         who are reluctant to engage in role-playing can be re-
ments can be shared out loud by the client when imi-           quested to read from a prepared script. As comfort in-
tating the model’s behavior (e.g., “Good for me for            creases, role-playing can be introduced. If a client is too
taking a chance”), and then, by instruction, gradually         anxious to read from a script, relaxation training may
moved to a covert level. Donald Meichenbaum in 1972            be offered as a prelude to role-playing. When there are
found that models who display coping responses (for            many skills to be learned, one behavior at a time may
example, they become anxious and then cope effec-              be focused on. Each role-play may be repeated until re-
tively with this) are more effective than are models who       quired levels of skill and comfort are demonstrated.
display mastery response (they do not experience any              Models and instructions are repeated as needed, and
difficulty in a situation).                                     rehearsal, prompts, and feedback continued until de-
   Effective behaviors may be modeled by the coun-             sired responses and comfort levels are demonstrated.
selor, or written scripts, audiotape, videotape, or film       Rehearsal alone (without previous model presentation
may be used. Essential elements of various responses           or other instructions), may be effective when skills are
can be highlighted and written models offered. The             available or relevant behaviors are simple rather than
advantage of written material is that it can be referred       complex. The situations used during role-playing
to on an as-needed basis. In addition, the client may          should be clearly described and closely resemble real-
be asked to observe people with effective behavior             life conditions. Instructions prior to practice or signals
who are in similar roles and to write down the situa-          during practice can be used to prompt specific re-
tion, what was done, and what happened. This in-               sponses. Instructions given before a client practices a
creases exposure to a variety of effective models, offers      behavior “prompt” her to engage in certain behaviors
examples to use during rehearsal and may increase              rather than others. Perhaps a client did not look at her
discrimination as to when to use certain behaviors and         partner during the role-play and is coached to look at
when not to do so, and offers opportunities for vicari-        others while speaking. Checklists may be prepared for
ous extinction of anxiety reactions through observa-           clients as reminders about effective behaviors. Covert
tion of positive outcomes following assertive behavior         modeling or rehearsal in which clients imagine them-
(that is, negative emotional reactions decrease via ob-        selves acting competently in social situations may be as
servation of what happens to others). The opportunity          effective as actual rehearsal if clients possess needed so-
to see how negative reactions to assertive reactions           cial behaviors (but do not use them) and if social anxi-
can be handled may be offered as well. Client observa-         ety is low. Home sessions in which clients engage in
tions are discussed, noting effective responses as well        covert rehearsal can be used to supplement rehearsal in
as other situations in which assertive behaviors may           office sessions. Not only does behavior rehearsal pro-
be usefully employed.                                          vide for learning new behaviors, it also allows their
                                                               practice in a safe environment and so may reduce dis-
                                                               comfort. Rehearsal involves exposure to feared situa-
   C. Behavior Rehearsal and Feedback
                                                               tions. This exposure is considered to be a key factor in
  Following model presentation, the client is re-              decreasing social anxiety, especially if people remain in
quested to practice (rehearse) the modeled behavior.           the situation even when they are anxious and act effec-
Corrective feedback is offered following each rehearsal.       tively in spite of their discomfort.
120                                                   Assertion Training

          D. Programming of Change                                statements (“I spoke up and it worked!”) for effective
                                                                  behavior. Practice, coaching, and model presentation
   Specific goals are established for each session. Per-           provide instruction concerning the essential elements
haps only one or two behaviors will be focused on in a            of effective behavior, and clients are encouraged to
session, or the initial repertoire might be such that all         vary their reactions in appropriate ways. As with any
needed verbal and nonverbal behaviors can be prac-                other assignment, a check is made at the next meeting
ticed. Assessment of the client’s behavior in relation to         to find out what happened. Client logs (records) de-
given situations will reveal available behaviors and              scribing relevant behaviors and the situations in
training should build on available repertoires. Hierar-           which they occurred can be used to provide a daily
chies ranked in terms of the degree of anxiety or anger           record of progress and guide selection of new assign-
that different social situations create can be used to            ments. Information reviewed may include what was
gradually establish effective assertive skills and lessen         said and done; when it was said and done; how the
anxiety. Rehearsal starts with situations creating small          client felt before, during, and after the exchange;
degrees of anger or anxiety. Higher-level scenes are in-          whether positive self-statements were provided for
troduced as anxiety or anger decreases. Thus, introduc-           trying to influence one’s social environment (even
tion of scenes is programmed in accord with the unique            though the attempt failed); and what consequences
skill and comfort levels of each client. Improvements             followed the client’s behavior. If an ineffective re-
are noted and praised. Praise for improvement should              sponse was given in a situation, clients can be asked to
be in relation to a client’s current performance levels.          write down one that they think would be more effec-
                                                                  tive. This will provide added practice in selecting ef-
                                                                  fective behaviors. Positive feedback is offered for
          E. Homework Assignments                                 effective behaviors, additional instructions given as
    After needed skill and comfort levels are attained, as-       necessary, and further relevant assignments agreed on.
signments, graded in accord with client comfort and               Motivation to act assertively may be enhanced by en-
skill levels, are agreed on to be carried out in the natural      couraging clients to carry out mini cost-benefit analy-
environment. Assignments are selected that offer a high           ses in situations of concern in which they compare
probability of success at a low cost in terms of discom-          costs and benefits of acting assertively (versus pas-
fort. Careful preparation may be required if negative re-         sively or aggressively).
actions may occur in real life. A clear understanding of
the social relationships in which assertive behavior is
proposed is needed to maximize the likelihood of posi-                     F. Cognitive Restructuring—
tive consequences and minimize the likelihood of nega-
                                                                           Changing What Clients Say
tive outcomes when assertive behaviors are used. For
example, a parent may be likely to become verbally abu-
                                                                                  to Themselves
sive if his son makes certain requests. This possibility             Thoughts relevant to assertive behavior include help-
should be taken into account (e.g., by encouraging be-            ful attributions (casual accounts or behavior), realistic
haviors unlikely to result in abuse, or by using some             expectations (“I may not succeed; no one succeeds all
other form of intervention such as family counseling).            the time”), helpful rules (“when in doubt think the
Coping skills should be developed to handle possible              best”), self-reinforcement for efforts to improve and pos-
negative reactions before asking the client to carry out          itive consequences, problem-solving skills, and accurate
new behaviors. With some behaviors, such as assertive             perception and translation of social cues (e.g., noting
behaviors in service situations, unknown individuals              and accurately interpreting a smile as friendly). In addi-
may be involved. Clients can be coached to identify situ-         tion, cognitive skills (e.g., distraction) are involved in
ations in which positive reactions are likely. For exam-          the regulation of affect (e.g., anger or anxiety). Unrealis-
ple, in service situations such as returning a defective          tic beliefs (such as “I must always succeed”) and other
purchase, clients can be coached to approach clerks who           kinds of thoughts such as negative self-statements that
appear friendly rather than ones who scowl and look as            get in the way of assertive behavior should be identified
if they have had a bad night.                                     and replaced by helpful self-statements and beliefs. This
    When effective social behavior occurs without diffi-          process is initiated during assessment and continues
culty in easy situations, more difficult ones are then            during intervention. Discussion of beliefs about what is
attempted. Clients are instructed to offer positive self-         proper assertive behavior and who has what rights
                                                      Assertion Training                                               121
should be held during assessment in the process of se-            sometimes followed by punishing consequences. Clients
lecting goals. Cognitive restructuring may include alter-         can be encouraged to reward themselves for making ef-
ing unrealistic expectations, altering attitudes about            forts to exert more effective influence over their social
personal rights and obligations, and/or self-instruction          environment, even though they are not always success-
training in which clients learn to identify negative self-        ful (e.g., if a woman tries to speak up more during a
statements related to effective social behavior and to re-        meeting and fails to gain the floor, she should reward
place them with positive self-statements.                         herself for trying).
   Self-management aspects of assertive behavior in-
clude identifying situations in which assertion is called
for (and when it is not), monitoring (tracking) the con-                     II. THEORETICAL BASES
sequence of assertion, and offering helpful self-feed-
back. The likelihood of effective social behaviors may               A key assumption behind assertion training is that we
be increased by covert (to one’s self) questions that             often lose out on positive outcomes or suffer negative
function as cues such as What’s happening?, What are              ones because of ineffective social behavior. For example,
my choices?, What might happen if…?, Which choice                 we may not get a job that we want because we lack the
is better?, How could I do it?, How did I do?                     skills to speak up and present ourselves well in a situa-
                                                                  tion. We may not be effective in meeting friends because
                                                                  we do not initiate conversations. A value stance as well
       G. Anxiety Reduction Methods
                                                                  as an intervention strategy is associated with assertion
   Relaxation training could be provided if anxiety in-           training. It is assumed that people have a right to express
terferes with use of assertive skills. The specific               their feelings in a manner that subjugates neither others
method selected to alter anxiety will depend on the               nor themselves, and that well-being includes this expres-
cause(s) of anxiety (e.g., negative thoughts, a past his-         sion. Joseph Wolpe and Andrew Salter emphasized the
tory of punishing consequences because of lack of                 importance of expressing our feelings, both positive and
skills), and/or unrealistic expectations (“Everyone               negative, in a way that does not detract from the rights
must like me”).                                                   and obligations of others. This applies to the overly reti-
                                                                  cent as well as to those who are overly aggressive. Those
                                                                  in the former group fail to assert their rights, whereas
       H. Encouraging Generalization
                                                                  those in the latter group achieve their goals at the ex-
             and Maintenance
                                                                  pense of others. Individual rights and obligations are
   Generalization refers to the use of assertive behaviors        emphasized in a context of increasing positive gains
in situations other than those in which training oc-              both for oneself and others. Such training implies that it
curred. Maintenance refers to their continued use over            is adaptive to express ourselves in appropriate ways, and
time. Steps that can be taken to increase the likelihood of       distinguish situations in which restraint is called for
generalization and maintenance of assertive behaviors             from those in which assertion would be best. It is con-
include recruiting natural reinforcers (e.g., involving sig-      sidered maladaptive and unfair to be taken advantage of,
nificant others), reinforcement for using behaviors in             to allow oneself to be unduly imposed on, and to be in-
new situations (e.g., self-reinforcement), and use of a va-       timidated. It is assumed that life will be more reinforcing
riety of situations during training. Generalization and           if we are active in the construction of our social environ-
maintenance can be encouraged by use of homework as-              ments. Obligations include considering the rights of oth-
signments and self-monitoring (e.g., keeping track of             ers. Clients are encouraged not only to consider their
successes). Situational variations that may occur in real         own rights and obligations in a situation but those of
life that influence assertive behavior should be included          others as well. What is viewed as a right or obligation
in practice examples to encourage generalization and              varies in different cultures and ethnic groups, and coun-
maintenance. For example, a woman may have difficulty              selors will have to be careful not to impose their cultural
refusing unwanted requests in a variety of situations             standards on groups in which these are not appropriate
(e.g., with friends as well as supervisors at work). If so,       (e.g., negative consequences and/or loss of positive con-
practice should be arranged in these different situations.        sequences may result). Steps are taken to deal with anxi-
Self-reinforcement may encourage the development and              ety about possible negative reactions by the development
maintenance of new behaviors. Such reinforcement may              of positive self-instructions and effective social and re-
be of special relevance in maintaining behaviors that are         laxation skills (as needed).
122                                                   Assertion Training

   It is assumed that behaviors, thoughts, and feelings are       variety of individuals, including college students, par-
interrelated. For example, negative thoughts about our-           ents, public welfare clients, people with various psychi-
selves may interfere with expressing and acting on our            atric diagnoses, and women. Group training may be
feelings (e.g., initiating conversations, answering ques-         especially important for women. Because of their social-
tions in class). These thoughts and lack of action may, in        ization, women compared to men may require more so-
turn, create anxiety or feelings of depression because of a       cial support and more opportunities to observe assertive
loss of positive consequences or negative consequences.           women in order for them to express their preferences.
If we speak up (assert ourselves) and acquire valued con-
sequences in situations in which we were reticent in the
past, this makes it easier to act on future occasions be-                     IV. EMPIRICAL STUDIES
cause we are less anxious. Joseph Wolpe emphasized the
importance of reciprocal inhibition; that is, if we engage           Both single case and group designs have been used to
in a response that is incompatiable with anxiety in a cer-        evaluate the success of assertion training. Single-case
tain situation, this will “countercondition” anxiety reac-        designs are uniquely suited for evaluating progress
tions and it will be easier to perform this opposite type of      with individual clients. Here, baseline levels of per-
response in the future. Speaking up rather than not say-          formance of an individual are compared with perform-
ing anything was viewed as one kind of incompatiable re-          ance levels of that individual during intervention.
sponse (i.e., to anxiety). Research in this area suggests         Research suggests that assertion training can be effec-
that it is exposure that contributes to positive effects.         tive with a number of different types of clients in pur-
That is, simply getting in a situation in which we are anx-       suit of a number of different outcomes. Programs
ious and performing effectively in that situation seems to        focused on altering cognitions believed to be related to
be the effective ingredient in decreasing anxiety and en-         ineffective social behavior have sometimes been found
couraging assertive behavior on future occasions.                 to be as effective as those focused on altering overt be-
                                                                  havior, suggesting an equivalence of effect across cog-
                                                                  nitive methods and assertion training. There are some
                III. APPLICATIONS                                 indications that a combination of methods is most ef-
                AND EXCLUSIONS                                    fective. However, some studies that purport to show
                                                                  that cognitive methods are as effective as social skills
   Assertion training requires a careful descriptive              training in enhancing social skills do not include indi-
analysis of relevant interpersonal relationships. If this         vidual assessment of specific entry level skills and do
analysis indicates that assertion would have unavoid-             not design individually tailored programs based on this
able negative effects, as it may for example in abusive           assessment. This lack may underestimate the potential
relationships, this would not be recommended. Other               value of assertion training. A number of studies show
methods must be explored. Clients must be willing to              that instructions alone (without modeling) are not suf-
act differently in real-life situations and have the self-        ficient to develop appropriate social behaviors with
management skills to do so (e.g., remind themselves to            some clients labeled “schizophrenic.”
act differently). Cultural differences regarding what be-            Comparison of the effectiveness of assertion training
haviors will be effective in certain social situations            in different studies is often hampered by the use of dif-
must be considered. Effective social behavior is situa-           ferent criteria for selection of subjects, different training
tionally specific; what will be effective in one situation         programs, and different criteria for evaluating progress.
may not be in another.                                            Evaluation is sometimes limited to changes in self-re-
   Assertion training may be carried out in groups. A             port or role-play measures, leaving the question unan-
group offers a number of advantages including a variety           swered as to whether beneficial changes occur in real
of models, multiple sources of support, normalization             life. Altering behavior in one kind of situation such as
and validation of concerns, and the availability of many          refusing requests, does not necessarily result in changes
people to participate in role-plays. Groups usually in-           in behavior in other kinds of situations such as initiat-
clude from 5 to 10 sessions lasting one and a half to two         ing conversations. Package programs may be used leav-
hours each. Decisions must be made about how to struc-            ing the question “What are the effective ingredients of
ture sessions (for example, each session could be struc-          assertion training?” unanswered. Use of package pro-
tured around a specific kind of assertive reaction).               grams may also be a waste of time and effort in includ-
Assertion training in groups has been carried out with a          ing unneeded components. Use of global self-report
                                                    Assertion Training                                                 123
measures to assess change in specific areas may result in        change. Feedback was provided concerning his per-
underestimating success of assertion training in rela-          formance after each role-play. Each response increased
tion to behavior in specific situations. Assertion train-        after specific instructions regarding this were given and
ing may do little to alter political, social, and economic      effects generalized to the specific situations that were
sources of inequity; it is individually focused. There is       problematic for this client. Ratings of his behavior were
thus the danger of blaming clients for problems that do         made by reviewing videotapes of his performance.
not originate with them. The ideology of success
through “mind power” (changing what you think),
which is especially prevalent in America where asser-                              VI. SUMMARY
tion training flowered, requires vigilance to discourage
programs that offer only the illusion of greater influ-             Assertion training is designed to increase competence
ence over one’s social environment.                             and decrease social anxiety in social interactions. It may
                                                                be carried out in individual or group meetings. Both
                                                                broad and narrow definitions of assertive behavior have
               V. CASE EXAMPLE                                  been used, ranging from definitions that restrict the
                                                                term to behaviors such as refusing unwanted requests to
   Richard Eisler and his colleagues Michel Hersen and          broad definitions that include a wide range of behaviors
Peter Miller in 1974 used assertion training with a 28-         involving the expression of both positive and negative
year-old house painter admitted to a hospital after he          feelings. The distinctions among assertive, passive
had fired a shotgun into the ceiling of his home. His his-       (doing nothing), and aggressive (e.g., yelling) behavior
tory revealed periodic rages following a consistent fail-       are made with assertion referring to effective behavior.
ure to express anger in social situations. His behavior         Assertive training differs from social skills training in its
was assessed by asking him to role-play in social situa-        emphasis on personal rights and obligations. There is a
tions in which he was unable to express anger. These in-        philosophy or ideology that accompanies assertion
cluded being criticized by a fellow employee at work,           training that does not accompany social skills training.
disagreeing with this wife about her inviting company           A number of procedures are usually involved in asser-
to their home without checking with him first, and his           tion training, including instructions, model presenta-
difficulty refusing requests made by his 8-year-old son.         tion, behavior rehearsal and coaching, feedback,
An assistant played the complementary role in each sit-         programming of change, homework assignments, and
uation (wife, son, or fellow employee). The client’s reac-      the cultivation of attitudes and beliefs that encourage
tions were videotaped and observed through a one-way            assertive behavior. The more outstanding the behavior
mirror. Review of data collected revealed expressive            deficits and need for behavior refinement, the more
deficits in four components of assertion: (1) eye contact        likely that instructions, model presentation, and re-
(he did not look at his partner when speaking to him),          hearsal will be required. Intervention may also include
(2) voice loudness (one could barely hear what he said),        efforts to replace negative thoughts with positive self-in-
(3) speech duration (responses consisted of one- or             structions. Homework assignments are a component of
two-word replies), and (4) requests (he did not ask his         assertion training, and client-recorded logs can be re-
partner to change his or her behavior).                         viewed to offer feedback and to encourage use of effec-
   Twelve situations that were unrelated to the client’s        tive skills. Careful assessment is required to identify
problem areas but that required assertive behavior were         skills needed and relevant situations, to determine
used during training. Each was role played five times in         whether there are discrimination problems in relation to
different orders over sessions. Instructions were given         when certain behaviors can most profitably be used, to
to the client through a miniature radio receiver. In-           identify unrealistic beliefs or expectations that may in-
structions related to only one of the four responses at         terfere with assertive behavior, and to determine
any one time. Thus during the initial scenes he was             whether negative self-statements or lack of effective
coached to look at his partner when speaking to him,            self-management skills interfere with effective behavior.
and during the second series he was coached to in-              Sources of assessment data include the interview, self-
crease the loudness of his voice but received no in-            report measures such as the Assertion Inventory, role-
structions concerning any other response. During the            playing, and observation in the natural environment.
fourth series, he was coached to speak longer, and dur-            Research to date indicates that assertion training is
ing the last, instructed to ask his partner for a behavior      effective in helping clients achieve a variety of valued
124                                                      Assertion Training

outcomes in real-life settings. Assertion training is usu-                              Further Reading
ally individually focused. It thus may not redress polit-
                                                                     Alberti, R. E., & Emmons, M. L. (2001). Your perfect right:
ical, social, and economic inequities that impede                       Assertiveness and equality in your life and relationships (8th
change. Planning for generalization and maintenance                     ed.). San Luis Obispo, CA: Impact.
will be required to increase the likelihood that desired             Assertion Inventory (2001). In K. Corcoran & J. Fischer
behaviors will occur in relevant situations and will be                 (Eds.), Measures for Clinical Practice: A sourcebook (3rd
maintained. Has the term “assertive behavior” outlived                  ed.) Vol. 2: Adults (pp. 64–65). New York: Free Press.
its usefulness? As a term connoting a traitlike approach                                                       .
                                                                     Eisler, R. M., Hersen, M., & Miller, P M. (1974). Shaping
                                                                        Components of Assertive Behavior with Instructions and
to behavior, it has. As a term that is sometimes con-
                                                                        Feedback. American Journal of Psychiatry, 131, 1344–1347.
fused with aggressive reactions, it has not been helpful.            Gambrill, E. (1995). Assertion training. In W. O’Donohue &
As a term that highlights our potential for influencing                  L. Krasner (Eds.), Handbook of psychological skills train-
our social environments, it has been helpful.                           ing: Clinical techniques and application (pp. 81–118).
                                                                        Boston: Allyn & Bacon.
                                                                     Meichenbaum, D. (1971). Examination of model characteris-
       See Also the Following Articles                                  tics in reducing avoidance behavior. Journal of Personality
                                                                        and Social Psychology, 17, 298–307.
Anger Control Therapy I Avoidance Training I                                      .
                                                                     Rakos, R. F (1991). Assertive behavior: Theory, research and
Bibliotherapy I Communication Skills Training I                         training. New York: Routledge.
Discrimination Training I Heterosocial Skills Training    I          Wolpe, J. (1973). The practice of behavior therapy. New York:
Homework                                                                Pergamon.
                        Assisted Covert Sensitization
                                                         Joseph J. Plaud
                   Cambridge Center for Behavioral Studies, New School for the Learning Sciences, and Brown University




    I.   Description of Treatment                                       of the precipitative events and thereby to decrease the
   II.   Theoretical Basis                                              undesirable behaviors. In 1990, the originator of the
  III.   Empirical Studies                                              procedure, Joseph Cautela and A. J. Kearney defined
  IV.    Clinical Case Study                                            the conditioning procedure as follows:
   V.    Summary
         Further Reading
                                                                              Covert conditioning refers to a family of behavioral
                                                                           therapy procedures which combine the use of imagery
                                                                           with the principles of operant conditioning. Covert
                            GLOSSARY                                       conditioning is a process through which private events
                                                                           such as thoughts, images, and feelings are manipulated
assisted covert sensitization A behavioral strategy in which               in accordance with principles of learning, usually oper-
   standardized scripts are employed to guide the client                   ant conditioning, to bring about changes in overt be-
   through clinically relevant scenarios in which ultimately               havior, covert psychological behavior (i.e. thoughts,
   aversive imaginal consequences are presented.                           images, feelings) and/or physiological behavior (e.g.
covert conditioning A family of behavior therapy procedures                glandular secretions).
   which combine the use of imagery with the principles of
   operant conditioning.
                                                                           In covert sensitization, the aversive stimulus usually
                                                                        consists of an anxiety-inducing or nausea-inducing
                                                                        image that may be presented verbally by the therapist or
         I. DESCRIPTION OF TREATMENT                                    imagined by the client. The aversive scene is individually
                                                                        created, and is specific to each client’s problem behavior.
   Covert sensitization represents one of the major psy-                Covert sensitization has frequently been successfully
chotherapeutic, behavioral techniques to be applied to                  employed by itself (as described by Brownwell and Bar-
the remediation of sexual deviations. Techniques such                   low in 1976; Curtis and Presley in 1972; Dougher,
as covert sensitization, olfactory aversion, and faradic                Crossen, Ferraro, and Garland in 1987; Haydn-Smith,
or electrical aversion therapy have in common the clin-                 Marks, Buchaya, and Repper in 1987; Hayes, Brownwell,
ical goal of reducing sexual arousal to deviant stimuli                 and Barlow in 1978; Hughes in 1977; King in 1990; Mc-
through the introduction of aversive events. Covert                     Nally and Lukach in 1991; and Maletzky and George in
sensitization is a form of conditioning therapy in which                1973) as well as in combination with other techniques
a behavior and its precipitative events are paired with                 (as discussed by Kendrick and McCullough in 1972;
some aversive stimulus in order to promote avoidance                    Moergen, Merkel, and Brown in 1990; Rangaswamy in


Encyclopedia of Psychotherapy                                                                        Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                          125                                                    All rights reserved.
126                                              Assisted Covert Sensitization

1987; and Stava, Levin, and Schwanz in 1993) in the               searchers found that in 45 cases, all of the patients held
treatment of sexual deviance.                                     this belief before their first deviant sexual encounter.
   Assisted covert sensitization is a basic variant of the        This leads one to the conclusion that the belief (a
covert sensitization procedure in which standardized              covert behavior) may play a precipitating role in the de-
scripts are employed to guide the client though clinically        velopment of sexual deviations (overt behaviors) rather
relevant scenarios in which ultimately aversive imaginal          than being an effect of the deviation.
consequences are presented. A study conducted by                     Sexual deviations may be best understood through a
Plaud and Gaither in 1997 illustrates the clinical                combination of classical and operant conditioning
methodology used in assisted covert sensitization, and            processes, according to O’Donohue and Plaud in 1994,
will now serve as a case illustration of the use of assisted      and Plaud and Martini in 1999. Deviant sexual behav-
covert sensitization in the treatment of a paraphilia.            ior begins with an accidental pairing of an “abnormal”
                                                                  or deviant stimulus with sexual arousal and/or ejacula-
                                                                  tion, giving this stimulus a high amount of erotic value.
            II. THEORETICAL BASIS                                 Thus, through a classical conditioning process, the de-
                                                                  viant stimulus begins to elicit sexual arousal. The de-
   The principles of learning and behavior have been              viant stimulus is then incorporated into sexual fantasies
integrated into many of the most commonly employed                during masturbation, which is reinforced by ejacula-
therapy techniques in use today with sexual devia-                tion. Thus, ejaculation serves as a reinforcer for the
tions, or the paraphilias, as discussed by Gaither,               covert behavior of deviant fantasizing.
Rozenkranz, and Plaud in 1998. Abel and Blanchard in
1976 stated 25 years ago that “The problem of deviant
sexual behavior was one of the earliest areas of psy-                            III. EMPIRICAL STUDIES
chopathology to which behavioral techniques were ap-
plied, and it continues to be a major area of research               McGuire and colleagues in 1965 discussed the impli-
and treatment.” The earliest behavioral theories of sex-          cations of their hypothesis for the treatment of sexual
ual deviations were based on a classical conditioning             deviations. First, the authors stated that “since the
paradigm. Theorists such as Binet in 1888, Jaspers in             original conditioning was carried out in most cases to
1963, and Rachman in 1961 believed that these devia-              fantasy alone, treatment also need only be to fantasy.”
tions were the result of accidental pairings between              Thus, in the treatment of deviations such as pedophilia,
stimuli that naturally elicited sexual arousal and origi-         it is not necessary to present the subject with children,
nally neutral stimuli. According to Jaspers in 1963,              but only with fantasies involving children. Another im-
“Perversion rises through the accidents of our first ex-           plication of this hypothesis is that therapists can warn
perience. Gratification remains tied to the form and               their patients of the conditioning effects of orgasm on
object once experienced, but this does not happen                 the immediately preceding fantasy. Finally, according to
simply through the force of simultaneous association              McGuire and colleagues, “positive conditioning to nor-
with that former experience.”                                     mal heterosexual stimuli can follow the same lines as it
   Why some individuals choose to incorporate deviant             is deduced that the deviation followed.”
stimuli into their masturbatory fantasies is also ex-                A study conducted by Lamontagne and Lesage in
plained using a conditioning hypothesis. One factor               1986 nicely illustrates the use of covert sensitization in
is the stimulus value of “deviant” stimuli, which is              the treatment of exhibitionism. The subject in this
continually strengthened through the pairing of these             study was a 37-year-old male who had been exposing
stimuli with ejaculation. According to a conditioning             himself several times per week. The treatment consisted
model, nondeviant stimuli or fantasies, at the same               of covert sensitization techniques and allowing the
time, undergo extinction (a decrement in responding)              client to privately expose himself at home with his
as a result of their lack of pairing with ejaculation. An-        wife. Before treatment, this client had fantasized about
other contributing factor is a common belief held by              exhibitionism approximately 60% of the time during
sexual deviants that a normal sex life is not possible.           masturbation, and 30% of the time during sexual inter-
This belief, according to McGuire and colleagues in               course with his wife. In the covert sensitization ses-
1965, may develop from a number of different sources              sions, the subject imagined exposing himself to a
including aversive adult heterosexual experiences, or             woman who would then angrily scold him. As another
feelings of physical or sexual inadequacy. These re-              part of the aversive image, he imagined losing his wife
                                                  Assisted Covert Sensitization                                         127
because of the exhibitionism. Thus, the deviant fantasy            of erection, and thereby preclude the occurrence of the
was paired with two powerfully aversive images. In                 deviant behavior.
combination with the covert sensitization procedures,                 Lamontagne and Lesage in 1986 combined classical
the client was allowed to expose himself two times per             conditioning and operant conditioning in their covert
week at home with his wife. This private exposure was              sensitization treatment approach. Another important
always followed by either masturbation or sexual inter-            part of their treatment consisted of the operant reinforce-
course without deviant fantasies. Also, the client was in-         ment of private exposure through orgasm from mastur-
structed not to masturbate unless his wife was present,            bation or intercourse, both of which took place with the
so that nondeviant sexual fantasy and behavior could be            client’s wife. Essentially, only the context of the exhibi-
promoted. A posttreatment follow-up indicated that the             tion behavior changed, not the behavior itself. The client
subject had not publicly exposed himself for 2 years. It           learned that the behavior would be reinforced in one sit-
would seem that the treatment rendered the exhibition-             uation (at home with his wife), while it would either be
ism appropriate, and even socially acceptable, since it            extinguished or punished in any other situations.
occurred in the privacy of the home. Interestingly, the
couple even reported that their sex life improved fol-
lowing treatment.                                                                 IV. CLINICAL CASE STUDY
   The underlying theory of this treatment approach is
probably best thought of as a combination of classical                The client in this case study of the use of assisted
and operant conditioning processes. The therapist works            covert sensitization was a 24-year-old male. The client
with a client to develop an aversive image that will be            was originally referred for a penile plethysmographic
paired with the precipitative events, and with the image           evaluation by a local human service center psycholo-
of the deviant behavior itself, according to a classical           gist in relation to a show cause hearing for his failure to
conditioning paradigm. The aversive image serves as the            progress in group treatment at the human service cen-
unconditioned stimulus (UCS). The images of the pre-               ter, which ultimately led to his termination from the
cipitative events, being continually paired with the UCS,          group. The group treatment focused on psychoeduca-
become the conditioned stimulus (CS). Both the condi-              tional issues relating to human sexuality, consent and
tioned response (CR) and the unconditioned response                victim empathy issues, appropriate and inappropriate
(UCR) consist of a negative reaction that may be emo-              sexual behavior, and disclosure to other members of
tional (e.g., fear), physiological (e.g., nausea), or in some      the group. The client chose not to participate actively
other way repulsive. Once the client’s deviant behavior            in any phase of the group treatment. The client had an
has been classically conditioned, the client should begin          extensive history of sexually abusive behavior. He ear-
to actively avoid or escape the situations associated with         lier pled guilty to a charge of sexual assault, and was
the deviant behavior. The precipitative events, as well as         serving probation at the time of the initiation of ther-
the behavior itself, should elicit a negative reaction, and        apy services. According to police records, when he was
thus be aversive.                                                  19 years old the client engaged in sexual activities with
   According to the principles of operant conditioning,            a 15-year-old male. The victim reported that the client
and specifically of negative reinforcement, the client              attempted anal intercourse on approximately 15 occa-
should behave in ways that would minimize contact                  sions. It was reported that the client ejaculated on a
with the aversive stimulus, in this case the precipitative         “couple” occasions, although there was no notation of
events and the deviant behavior. If the client does pur-           anal penetration, oral sexual contact, or masturbation.
sue the deviant behavior further, hopefully the treat-             The victim also reported on several of these sexual en-
ments will have at least reduced the effectiveness of the          counters that the client would gain compliance by the
reinforcement for the deviant behavior, which should               victim through purchasing soft drinks, and that con-
lead to a lower frequency of the behavior. It would also           sent by the victim to sexual interactions was verbally
be possible for classical conditioning to work alone, if           coerced by the client. The client denied engaging in
the CR was so powerful that it rendered the person un-             anal intercourse and verbally coercive activities, and in-
able to engage in the deviant behavior, or consisted of a          dicated that the victim engaged in sexual activities, in-
response that was incompatible with the deviant behav-             cluding masturbation, in a mutual fashion.
ior. For example, if the CR was extreme anxiety or fear,              The client’s penile responses during the course of
and the deviant behavior required an erect penis, it may           therapy were recorded by a penile plethysmograph uti-
be the case that the CR would preclude the possibility             lizing a Type A mercury-in-rubber penile strain gauge.
128                                            Assisted Covert Sensitization

During the original assessment of the client’s sexual              Following a 10-minute break the treatment was initi-
preferences, penile tumescence was continually moni-            ated, involving the presentation of 10 MPF stimuli de-
tored as he listened to sexually explicit audiotapes. A         scribed earlier. At the end of the session, the client was
total of 18 standard audio scripts were presented dur-          given a copy of the tape and instructed to listen to and
ing the initial assessment. These were descriptions of          visualize the sexual activity as well as the aversive con-
two adult homosexual interactions, two adult hetero-            sequences being delivered five times per day. The re-
sexual interactions, two acts of adult female exhibition-       maining five sessions were conducted at 1-week
ism, two adult female rapes, one male child physical            intervals apart beginning with Session 1.
aggression, one female child physical aggression, one              During Session 2, the client was presented with the
male child nonphysical coercion, one female child non-          same 10 MPF stimuli from the previous session, and
physical coercion, three male child fondling, and three         again instructed to listen to the tape five times per day
female child fondling. The client’s subjective reports of       until the next session. In Sessions 3 and 4, the same
sexual arousal were assessed by having him rate how             procedures were followed with the exception that
aroused he felt using a 10-point Likert scale (0 = not at       MPF stimuli were presented only two times and FPC
all aroused, 9 = extremely aroused).                            stimuli were presented the other times. The client was
   Results of this assessment component before initiat-         again provided with a copy of the new tape and in-
ing assisted covert sensitization indicated that the            structed to listen to it five times per day between ses-
client was aroused by adult females; however, he also           sions (with explicit instructions to visualize the
displayed an active pattern of arousal toward stimuli           stimuli being presented). In Sessions 5 and 6 FPF
depicting sexual activities with a male child, specifi-          stimuli were presented six times, MPF two times, and
cally anal intercourse. Based on these data, three “de-         FPC two times each.
viant” categories that elicited the greatest levels of             After completion of Session 6, the client returned to
sexual arousal—fondling a male child (MPF), coercing            the clinic for a 30-day follow-up assessment. The same
a female child into sexual activity (FPC), and fondling
                                                                stimuli from the baseline assessment were used to de-
a female child (FPF)—were noted, and a follow-up rec-
                                                                termine present patterns of sexual arousal. The same
ommendation was made for the client to participate in
                                                                procedure was again followed 3 months later in a final
eight sessions of assisted covert sensitization in addi-
                                                                follow-up assessment.
tion to being readmitted to group treatment at the local
                                                                   The client’s physiological data for the initial assess-
human service center.
                                                                ment, pretreatment assessment, 30-day follow-up,
   Shortly after the initial assessment was conducted,
                                                                and 90-day follow-up were calculated and converted
an assisted covert sensitization protocol was begun.
                                                                to percentages of full erection. This was computed by
The client was given a consent form and full explana-
tion of the procedure, and all questions were answered          subtracting his minimum penile circumference for an
concerning the procedure. The initial assisted covert           entire session (e.g., assessment period) from his max-
sensitization session was scheduled for the following           imum penile circumference for each trial (the presen-
week. During the week, audiotapes were developed for            tation of one audiotaped stimulus represents a trial)
treatment. These tapes contained 3-minute descrip-              and dividing this number by 3. Three centimeters is
tions of a deviant sexual activity (MPF FPC, or FPF)
                                          ,                     thought to reflect the circumference change most
followed by a description of a possible negative (aver-         males undergo from flaccidity (no sexual arousal) to
sive) consequence for this type of activity. The conse-         complete engorgement (maximum sexual arousal).
quences were either legal (e.g., being beaten up by the         This number was then multiplied by 100 to give a per-
father of the child and then being arrested) or physio-         centage of full erection. Thus, percentage of full erec-
logical (e.g., feeling very nauseous and vomiting) in na-       tion data give an indication of absolute levels of
ture. The development and implementation of these               arousal. In other words, the client’s response to each
guided scripts represents the “assisted” component in           stimulus is viewed in this manner independently of
assisted covert sensitization.                                  the other stimuli presented in the session. It was
   When the client arrived for the first session, an ab-        found that the stimuli elicited less arousal each time
breviated assessment was conducted to obtain base-              the client was assessed during the assisted covert sen-
line measurements of his sexual arousal to MPF FPC,
                                                  ,             sitization procedure.
and FPF stimuli, as well as mutually consenting het-               The client’s physiological data for the assessments
erosexual (FAD), and mutually consenting homosex-               were next converted to standardized scores (z-scores).
ual (MAD) activity.                                             Z-scores form a distribution in which the mean of the
                                                Assisted Covert Sensitization                                               129
distribution equals zero (0) and the standard devia-                                  V. SUMMARY
tion is 1.0. Using this scoring method, the client’s sex-
ual preferences are expressed as positive z-scores,                 Assisted covert sensitization represents an empiri-
while negative z-scores reflect sexual aversions. The            cally validated approach to treating sexually deviant
greater that a score falls from zero, the stronger the           behavior patterns, focusing on both the covert and
preference or aversion. Thus, a score of +2.0 indicates          overt behavioral manifestations of inappropriate sexual
a greater preference than a +1.2, while a score of –2.0          arousal patterns, and therefore assisted covert sensitiza-
indicates a greater repulsion than a score of –1.2. Z-           tion is a main line behavior therapy technique in the
scores, then, give an indication of relative arousal or          treatment of sexual offenders.
preferences and aversions among a group of stimuli. It
was found that in the initial assessment, four of the                    See Also the Following Articles
five categories including the three that were treated,
                                                                 Coverant Control I Covert Positive Reinforcement I
were positive and above 0.50. Looking across the as-
                                                                 Covert Reinforcer Sampling I Orgasmic Reconditioning I
sessments for each of the deviant categories, it was             Self-Control Desensitization I Sex Therapy I Systematic
clear that the client’s arousal to these decreased across        Desensitization
time, although his arousal to adult mutually consent-
ing sexual activity (FAD) indicated that this was
clearly his most preferred stimulus in all assessments                              Further Reading
except for the 30-day follow-up, in which mutually               Abel, G. G., & Blanchard, E. B. (1976). The measurement
consenting heterosexual activity (MAD) was the most                 and generation of sexual arousal in male sexual deviates.
preferred stimulus.                                                 In M. Hersen, R. Eisler, & R. M. Miller (Eds.), Progress in
   The client’s self-report of sexual arousal using the 10-         Behavior Modification, Vol. 2 (pp. 99–133). New York: Aca-
point Likert scale (0 = not at all aroused, 9 = extremely           demic Press.
aroused) for each category of stimulus across the four as-       Binet, A. (1888). Le fetichisme dans l’amour. Paris. Doin, ed.
sessments, yields an indication of an individual’s subjec-       Brownwell, K. D., & Barlow, D. H. (1976). Measurement and
tive experience of arousal, which is not always perfectly           treatment of two sexual deviations in one person. Journal of
                                                                    Behavior Therapy and Experimental Psychiatry, 7, 349–354.
related to his physiological responding. Once again, it
                                                                 Cautela, J. R., & Kearney, A. J. (1990). Behavior analysis, cog-
was found that FAD stimuli elicited the greatest levels of          nitive therapy and covert conditioning. Journal of Behavior
arousal, whereas all others dropped off to 0.                       Therapy and Experimental Psychiatry, 21, 83–90.
   The client clearly showed clinical progress in both           Curtis, R. H., & Presley, A. S. (1972). The extinction of ho-
his physiological and self-report of arousal toward                 mosexual behaviour by covert sensitization: A case study.
sexually deviant stimuli that were the main areas of                Behavior Research and Therapy, 10, 81–83.
concern, using the assisted covert sensitization proce-                                                          .,
                                                                 Dougher, M. J., Crossen, J. R., Ferraro, D. P & Garland, R.
dure. Recall that the underlying behavior principle of              (1987). The effects of covert sensitization on preference
covert sensitization is most often theorized to be a                for sexual stimuli. Journal of Behavior Therapy and Experi-
                                                                    mental Psychiatry, 18, 337–348.
combination of classical and operant conditioning, as
                                                                 Gaither, G. A., Rosenkranz, R. R., & Plaud, J. J. (1998). Sex-
described earlier. Given decrements in physiological                ual disorders. In J. J. Plaud & G. H. Eifert (Eds.), From be-
arousal and self-report normally observed in covert                 havior theory to behavior therapy (pp. 152–171). Boston:
sensitization procedures, such as in the present case               Allyn & Bacon.
study, it is logical to conclude that the aversive image         Haydn-Smith, P., Marks, I., Buchaya, H., & Repper, D.
associated with deviant sexual arousal (the UCS) be-                (1987). Behavioral treatment of life threatening masochis-
comes a CS by virtue of its being contingently paired               tic asphyxiation: A case study. British Journal of Psychiatry,
with the UCS (classical conditioning). Also, it is logi-            150, 518–519.
cal and theoretically coherent to conclude that both             Hayes, S. C., Brownwell, K. D., & Barlow, D. H. (1978). The
                                                                    use of self-administered covert sensitization in the treatment
the conditioned response (CR) and the unconditioned
                                                                    of exhibitionism and sadism. Behavior Therapy, 9, 283–289.
response (UCR) consist of a negative reaction that               Hughes, R. C. (1977). Covert sensitization treatment of exhi-
may be emotional (e.g., fear), physiological (e.g., nau-            bitionism. Journal of Behavior Therapy and Experimental
sea), or in some other way repulsive, which further                 Psychiatry, 8, 177–179.
serves to negatively reinforce avoidance or escape be-           Jaspers, K. (1963). General psychopathology. Manchester,
havior (operant conditioning).                                      England: Manchester University Press.
130                                                  Assisted Covert Sensitization

                                     .
Kendrick, S. R., & McCullough, J. P (1972). Sequential phases            ment of an obscene telephone caller. Journal of Behavior
  of covert reinforcement and covert sensitization in the                Therapy and Experimental Psychiatry, 21, 269–275.
  treatment of homosexuality. Journal of Behavior Therapy             O’Donohue, W. T., & Plaud, J. J. (1994). The conditioning of
  and Experimental Psychiatry, 3, 229–213.                               human sexual arousal. Archives of Sexual Behavior, 23,
King, M. B. (1990). Sneezing as a fetishistic stimulus. Sexual           321–344.
  and Marital Therapy, 5, 69–72.                                      Plaud, J. J., & Gaither, G. A. (1997). A clinical investiga-
Lamontagne, Y., & Lesage, A. (1986). Private exposure and                tion of the possible effects of long-term habituation of
  covert sensitization in the treatment of exhibitionism. Journal        sexual arousal in assisted covert sensitization. Journal of
  of Behavior Therapy and Experimental Psychiatry, 17, 197–201.          Behavior Therapy and Experimental Psychiatry, 28,
                               .
Maletzky, B. M., & George, F S. (1973). The treatment of ho-             281–290.
  mosexuality by ‘assisted’ covert sensitization. Behavior Re-        Plaud, J. J., & Martini, J. R. (1999). The respondent condi-
  search and Therapy, 11, 655–657.                                       tioning of male sexual arousal. Behavior Modification, 23,
McGuire, R. J., Carlisle, J. M., & Young, B. G. (1965). Sexual           254–268.
  deviation as conditioned behavior. Behavior Research and            Rachman, S. (1961). Sexual disorders and behavior therapy.
  Therapy, 2, 185–190.                                                   American Journal of Psychiatry, 118, 235–240.
McNally, R. J., & Lukach, B. M. (1991). Behavioral treatment          Rangaswamy, K. (1987). Treatment of voyeurism by behavior
  of zoophilic exhibitionism. Journal of Behavior Therapy and            therapy. Child Psychiatry Quarterly, 20, 73–76.
  Experimental Psychiatry, 22, 281–284.                               Stava, L., Levin, S. M., & Schwanz, C. (1993). The role of
Moergen, S. A., Merkel, W. T., & Brown, S. (1990). The use of            aversion in covert sensitization treatment of pedophilia: A
  covert sensitization and social skills training in the treat-          case report. Journal of Child Sexual Abuse, 2, 1–13.
                     Attention Training Procedures
                                                       Alice Medalia
                                                 Albert Einstein College of Medicine




    I.   Description of Treatment                                         Attention training refers to the procedures used to
   II.   Theoretical Bases                                              improve attention deficits as they impact on cognitive
  III.   Empirical Studies                                              and social aspects of functioning. This article reviews
  IV.    Summary                                                        the various training techniques that are used, the con-
         Further Reading
                                                                        ceptual underpinnings of the treatment procedures,
                                                                        and studies of treatment efficacy.

                            GLOSSARY
                                                                             I. DESCRIPTION OF TREATMENT
anhedonia A psychological condition evidenced as an inabil-
   ity to experience pleasure in activities that normally pro-             Remediation of attentional impairments is ap-
   duce it.
                                                                        proached with different techniques depending on the
avolition Lack of intent or will to perform activities.
                                                                        aspect of attention that requires improvement, and the
contextualization Placing the learning exercise in a context
   so that the practical utility and link to everyday interests         specific characteristics of the population being treated.
   and activities are obvious to the learner.                           The actual process of remediating attention typically
errorless learning The elimination of trial and error ap-               includes various exercises that are done in a controlled
   proaches to learning by beginning with easily mastered ex-           treatment setting with the ultimate goal of increasing
   ercises and slowly increasing the difficulty level.                   attention performance in everyday life. Before treat-
generalization The transfer of a learned skill or behavior to           ment begins, assessment of the particular needs of the
   other situations besides the one where the training oc-              patient is done. This assessment forms the basis for a
   curred.                                                              treatment plan, and also can serve as a baseline meas-
intrinsic motivation The motivation to do an activity be-               ure in studies of treatment effectiveness.
   cause performance of that activity is in and of itself re-
   warding. Contrasts to extrinsic motivation, which
   occurs when there are external rewards for performing                                  A. Assessment
   an action.
reaction time Time taken to respond to an auditory, visual, or             The assessment includes a thorough history that helps
   proprioceptive stimulus.                                             to identify the etiology of the attention problems. Med-
shaping Process of systematically reinforcing an individual             ical and psychiatric history identifies conditions known
   for demonstrating behaviors that increasingly approximate            to affect attention and other cognitive functions, and es-
   a target behavior.                                                   tablishes the extent to which attention problems are



Encyclopedia of Psychotherapy                                                                       Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                          131                                                   All rights reserved.
132                                             Attention Training Procedures

state (episode) versus trait (interepisode) related. Cur-        measures to show that the attention training has gener-
rent medications and other treatments are reviewed with          alized outside the remediation setting. The interven-
note made of how they are tolerated by the individual.           tions indicate the actual attention training procedures
Medication and electroconvulsive therapy (ECT) in-               to be used and the person who will be doing them.
duced attention impairment is treated by titrating the
dose, or changing drug class to minimize cognitively
                                                                            C. Treatment Interventions
toxic effects. Assessment also includes educational and
occupational history to identify baseline/premorbid func-        1. Computer-Based
tioning. Current functioning is reviewed with an empha-             There are several computerized attention training ex-
sis on identifying how attentional impairments are               ercises that have been developed for head-injured pa-
evidenced in everyday life. Ability to attend during thera-      tients and these have also been used with psychiatric
peutic activities, at school, in work, and in social situa-      populations. The Orientation Remedial Module (ORM)
tions is evaluated. Some formal testing of attention is          is a program developed at NYU Rusk Institute that has a
done to provide objective data on how the patient’s atten-       number of attention training exercises and a reaction
tion compares to a normative group. This testing in-             time test that can be administered before and after each
cludes measures of different aspects of attention such as        training session. The tasks are intended to improve
ability to encode, focus, and sustain attention. Some of         arousal, alertness, rapid and well-modulated responsive-
the commonly used tests are Digit Span, Coding, Cancel-          ness, scanning, target detection, and rapid processing of
lation Tests, Continuous Performance Test (CPT), as well         simple information. There are five modules (attention
as others. Ability to stay on task in therapeutic or voca-       reaction conditioner, zeroing accuracy conditioner, vi-
tional activities may be quantified as time on task or rated      sual discrimination conditioner, time estimates, and
with scales. Some assessment of differences in ability to        rhythm synchrony conditioner) that involve receiving
attend to auditory versus visual stimuli can be done.            auditory and visual stimuli and eliciting a series of sim-
   Learning style is discussed as a way of increasing and        ple visual–motor responses. Progression through one
assessing patient awareness of cognitive strengths and           module builds skills necessary for subsequent modules.
weaknesses. Patient awareness of attention deficit and            The tasks are somewhat engaging and feedback is pro-
how it impacts on their functioning is assessed, as is           vided to the patients about their performance.
motivation for treatment and attitude about learning.               Captain’s Log software, available through BrainTrain,
Ultimately, this assessment identifies how attention              and the training exercises developed by Bracey are ex-
processes are functioning relative to those of an age            amples of other computer-based cognitive training
(and education) matched group, possible etiologies for           packages that include tasks intended to improve audi-
the impairment, areas to focus on in attention remedia-          tory and visual attention. There are a number of soft-
tion, and treatment techniques most suited to the                ware exercises available through different vendors, all
learning style and needs of the patient. The assessment,         designed to improve attention, in head-injured or
inasmuch as it is done in one of the first meetings with          ADHD populations. Although there is no software de-
the cognitive remediation staff, should also serve to en-        signed specifically for use by psychiatric populations,
gage the patient in treatment. As in any first therapeu-          some success has been reported in the application of
tic encounter, the cognitive remediation assessment not          the exercises to this patient group. Psychiatric patients
only assesses but also lays the groundwork for a pro-            often have severe motivational problems that can affect
ductive therapeutic collaboration between the patient            response to any treatment. Characteristics of software
and the provider.                                                that are best suited to populations with motivational
                                                                 problems include engaging presentation of material,
                                                                 options for personalizing and controlling aspects of the
                B. Treatment Plan
                                                                 task, frequent feedback, and placing the activity in ap-
   A treatment plan in cognitive remediation delineates          pealing, relevant contexts. Educational software, devel-
the overall goal, the specific objectives, and the inter-         oped for use in primary and secondary curriculums, is
ventions. For example, the overall goal may be to im-            frequently designed with these features, and some in-
prove ability to focus and sustain attention. The specific        clude exercises to improve attention and memory.
objectives may be to increase ability to stay on task               Computer-based software exercises are intended to
from 15 minutes to 45 minutes, or to improve perform-            be worked on by individuals, but it is possible to have
ance on the CPT. Specific objectives include some                 several individuals working simultaneously at separate
measures of test performance and some functional                 computer stations. Depending on the patient profiles,
                                                 Attention Training Procedures                                           133
one therapist typically works with one to four clients.           3. Holistic versus Targeted Treatment
The therapist monitors and facilitates productive en-             Approaches
gagement in the activity and guides the patient to ap-               Attention training is typically done in the context of
propriate exercises.                                              a comprehensive treatment program. Whereas a tar-
                                                                  geted approach would focus on the purely cognitive,
2. Noncomputer-Based                                              nonsocial aspects of attention, a holistic approach ad-
   Attention is sometimes the focus of group exercises            dresses both the cognitive and social aspects of atten-
done within the context of psychiatric rehabilitation.            tion. Issues of awareness, self-esteem, and learning
These exercises are rarely as purely cognitive as those           style are appreciated as having a potential impact on
done on the computer and are often done in conjunc-               cognition, and they are therefore addressed in the re-
tion with the computer exercises to facilitate general-           mediation sessions.
ization to an ecologically meaningful context. For
example, Integrated Psychological Therapy (IPT) is a              4. Intensity and Duration of Treatment
highly structured group therapy approach that includes               There are no conclusive data to provide guidelines
five subprograms, three of which are devoted to devel-             on these treatment parameters. Many studies of treat-
opment of those cognitive abilities thought to be the             ment efficacy used a model of three sessions per week.
prerequisite for effective social interaction. Attention is       There is considerable variability in the duration of
the focus of a few of these IPT exercises; for example,           treatment. The more comprehensive programs, which
one task requires verbatim repetition and paraphrasing            target several cognitive functions in addition to psy-
of what another group member said. A wide variety of              chosocial skills, typically involve 6 to 12 months. More
other group exercises that target attention can be ac-            focused programs, which target nonsocial aspects of
cessed through occupational therapy manuals. For ex-              cognition, typically involve 10 to 24 sessions. The
ample, a group exercise to tone visual scanning and               length of each treatment session may vary from 30 to
vigilance may involve a version of I Spy, whereby pa-             60 minutes.
tients search a highly intricate picture for target objects.
   For those clients who are so severely attentionally
impaired that they are unable to tolerate group for-                             II. THEORETICAL BASES
mats, behavioral techniques such as shaping can be
integrated into the skills training. Shaping refers to               Impairment in attention is a common symptom of se-
the systematic reinforcement of behaviors that in-                vere psychiatric illness. Patients with schizophrenia per-
creasingly approximate a target behavior. When the                form poorly on tasks that require vigilance, quick
goal is to enhance social attention, the behaviors that           responses, or sustained attention. Because these deficits
indicate attentiveness, such as keeping eyes open or              are evident during and between episodes of active psy-
looking at the speaker, can be reinforced. Shaping                chosis and have been noted in individuals at risk for
techniques can be used to enhance social aspects of at-           schizophrenia, they are considered to be trait or vulnera-
tention or to develop attention in nonsocial contexts             bility markers of the disease. Patients with bipolar and
such as target detection.                                         unipolar depression, especially if the illness is treatment
   Other noncomputer-based attention tasks can be                 refractory or has accompanying psychotic features, also
done individually or in a group with each patient work-           have severe problems with attention. Attention has sev-
ing on his or her own exercises. Some exercises are ac-           eral aspects, and it is possible for some elements of atten-
tually versions of attention tests that are instead used to       tion to remain intact while others are deficient. For
train performance. For example, cancellation tasks that           example, the ability to encode information, which can be
require the patient to scan a paper and mark all the tar-         measured by Digit Span, is differentiated from the ability
get stimuli, and coding tasks that are similar to Digit           to sustain attention and maintain readiness to respond to
Symbol, can be used as a remediation or assessment                a signal. Tasks such as the CPT measure vigilance or abil-
tool. These exercises are best used in conjunction with           ity to sustain attention, ability to be ready to respond to a
other tasks since there is a disadvantage associated with         target, and not to respond to noise or nontargets.
exclusive use of outcome measures as a remediation                   Impairments in attention have been associated with
tool. Generalization of skill is promoted when target             functional outcome in psychiatric patients. In schizo-
behaviors are paired with multiple cues in multiple               phrenia, impaired encoding and vigilance has consis-
contexts, something that does not happen when the                 tently been associated with poor social problem
outcome measure is the only remediation tool used.                solving and difficulty benefitting from rehabilitation
134                                            Attention Training Procedures

services. Psychosocial skills training is a form of reha-       different anatomic areas that together work as a net-
bilitation that is widely available for people with per-        work. Neuropsychology has emphasized the impor-
sistent psychiatric illness, and it is intended to teach        tance of studying the cognitive origins of psychiatric
basic life skills such as social interacting, illness man-      disorders. From this perspective, the disorders in atten-
agement, independent living, and leisure skills. The            tion and information processing are seen as critical
patients with schizophrenia who have more severe at-            links in the causal chain leading to formation of schiz-
tentional problems are least likely to acquire skills in        ophrenic symptoms. Attention impairments are not
these programs. The attentional problems make it dif-           necessarily seen as directly causal in symptom forma-
ficult for them to process the information given in             tion but rather as a vulnerability factor that when cou-
groups, and they may not be able to sustain attention           pled with other vulnerability factors and stresses,
for the duration of the sessions.                               contribute to the onset of psychosis. Sometimes these
   Medication does not have a major impact on atten-            attention deficits are referred to as nonsocial cognitive
tion in schizophrenia. There appears to be a positive           deficits, inasmuch as they refer to pure cognitive func-
impact on the gross attentional problems associated             tioning, or the basic cognitive processes that operate
with acute psychotic decompensation but the enduring            regardless of environmental context. The profile of at-
attentional problems that are seen throughout the               tention impairment informs the intervention strategy.
course of the illness are surprisingly resistant to med-        Those deficits that are vulnerability factors or that limit
ication. In the affective disorders, medication can sig-        functional outcome are considered the important ones
nificantly reduce attention problems if attentional             to target for intervention.
deficits are state related and the illness responds to psy-         Attention remediation has long been the focus of
chopharmacologic intervention. In the treatment re-             treatment in programs for the head injured and many
fractory patients, attentional problems tend to persist.        remediation exercises have been developed to improve
Furthermore, some medications, such as lithium, can             attention in the head injured. These exercises show the
impair attention. Many medications, if not in the thera-        influence of neuropsychological models of attention in
peutic range, or if idiosyncratically tolerated, can cause      their singular focus on specific nonsocial aspects of at-
attention impairment.                                           tention. The ability to focus, encode, rapidly process
   Because attentional problems are so prevalent in the         and respond, maintain vigilance, and avoid distraction
psychiatric disorders, often so unresponsive to pharma-         from competing stimuli, are all aspects of attention that
cological intervention, and because they are associated         may be isolated for remediation in these exercises.
with outcome and ability to benefit from treatment,              Often these exercises are computerized to facilitate
they are targeted for remediation. This remediation is          standardization of presentation, precise measurement
typically done within the context of rehabilitation pro-        of response, and frequent feedback. Because nonsocial
grams, serving people who have persistent psychiatric           aspects of attention have been identified as vulnerabil-
illness. As acute care has become increasingly triage           ity factors in schizophrenia, the exercises are consid-
oriented, remediation of cognitive deficits is more             ered relevant in psychiatric rehabilitation as well.
likely found in outpatient settings or long-term inpa-             Given the ultimate goal of improving attention in
tient facilities. Major influences on the development of         real-life contexts it is important that the gains made on
attention remediation models in psychiatry come from            laboratory tasks of attention generalize outside the re-
neuropsychology, behavioral learning theory, educa-             mediation setting. For this to happen there must be an
tional theory, and rehabilitation psychology.                   appreciation of how skills are best learned and what
                                                                factors influence recovery. It is in this regard that learn-
                                                                ing and educational theory, and rehabilitation psychol-
           A. Neuropsychology and
                                                                ogy have had the most influence.
            Attention Remediation
  Neuropsychology, and the related field of cognitive                           B. Learning Theory and
psychology, have made major contributions to our un-
                                                                               Attention Remediation
derstanding of the attentional system, at the levels of
both cognitive operations and neuronal activity. The at-           The use of techniques such as shaping, errorless
tention system is believed to be composed of subsys-            learning, and frequent positive feedback show the in-
tems that perform different but interrelated cognitive          fluence of behavioral and learning theory. Errorless
functions. These different subsystems are mediated by           learning refers to the careful titration of difficulty level
                                                Attention Training Procedures                                          135
so that the patient learns without resorting to trial and        occurs when the patient can choose task features such
error, and has a positive experience with increasing             as difficulty level or presence of additional auditory
challenge. Shaping and positive feedback are integral            cues when doing a visual vigilance exercise. Intrinsic
components of the social learning approach of Paul and           motivation, depth of engagement in the task, amount
Lentz, and have been used extensively to decrease mal-           learned, and self-efficacy can all be increased when task
adaptive behaviors in the chronic, highly regressed psy-         design incorporates educational principles.
chiatric patient. Although Paul’s social learning
approach was not developed for use with cognitively                       D. Rehabilitation Psychology
impaired individuals, methods such as shaping and
                                                                           and Attention Remediation
positive reinforcement have since been found effective
for treating attention impairment. Learning theory has              Rehabilitation psychology emphasizes an integrated
also indicated some of the factors that promote general-         approach to the patient that appreciates the complex
ization of skill. Within the remediation exercises, target       interaction of cognitive, emotional, and environmental
behaviors need to be paired with multiple cues, ideally          variables in the recovery process. From this perspec-
in various contexts, so that the behavior will be elicited       tive, attention deficits are not seen simply as a manifes-
in multiple settings. In attention training this occurs          tation of neuropsychological dysfunction, but rather
when the focus/execute response is paired with audi-             social–cognitive dysfunction. Rehabilitation psychol-
tory, visual, and social cues in a variety of tasks. Pa-         ogy favors a more interactive, learning process ap-
tients who do multiple tasks that exercise the ability to        proach to attention remediation over the formal
focus and quickly execute a response are more likely to          didactic exercises used in a purely cognition-oriented
improve than those whose training is limited to repeti-          program. This allows for the social and emotional as
tive execution of one task.                                      well as the cognitive needs of the patient to be ad-
                                                                 dressed and promotes a smooth interplay of cognitive
                                                                 and emotional variables in everyday functioning.
          C. Educational Psychology
          and Attention Remediation
                                                                            E. Rationale for Computer-
   Apathy, anhedonia, and avolition are frequent symp-
                                                                                Assisted Exercises
toms in the severely mentally ill, and these motiva-
tional problems compromise engagement in treatment.                 Computer-based technology is used in attention train-
Educational psychology has shown that engagement in              ing because it is possible to give frequent and consistent
a learning activity is most likely to occur when the per-        feedback, there are opportunities for positive reinforce-
son is intrinsically motivated, that is, when the person         ment, the learning experience can be individualized and
finds the learning experience compelling and not when             personalized, there are opportunities for giving control
the person is compelled by external forces to do it. In-         over the learning process, difficulty levels can be individ-
trinsic motivation and task engagement occur when                ualized so that the task is challenging but not frustrating,
the tasks are contextualized, personalized, and allow            and the student can be given ample opportunity to apply
for learner control. Contextualization means that                the targeted skill in contextualized formats. The com-
rather than presenting material in the abstract it is put        puter itself simply provides the overall learning platform;
in a context whereby the practical utility and link to           the software provides the learning tools. The design of
everyday life activities are obvious to the student. In at-      the software program and whether or not it incorporates
tention remediation, a decontextualized focusing task            basic educational principles, largely dictates whether the
would require the person to press a button every time a          remediation experience will be frustrating or engaging.
red square appeared on the otherwise blank computer              Computer exercises exert a remedial effect on attention
screen. A contextualized focusing task would require             through two broad categories of mechanisms: specific
the person to assume the role of pedestrian in a task            and nonspecific. Specific mechanisms refer to those as-
that simulated the experience of responding to cross-            pects of the activity that focus specifically on attention.
walk signals. Personalization refers to the tailoring of a       The nonspecific mechanisms refer to those aspects of
learning activity to coincide with topics of high interest       computer activity that promote or facilitate skill acquisi-
value for the student. Learner control refers to the pro-        tion without directly targeting attention. An example of a
vision of choices within the learning activity, in order         nonspecific mechanism would be self-pacing, an option
to foster self-determination. In attention training, this        many tasks provide. Self-pacing provides a measure of
136                                             Attention Training Procedures

control, which is known to facilitate learning. Both the         distraction from competing stimuli. These aspects of at-
specific and nonspecific mechanisms contribute mean-               tention can be differentially impaired and the first step in
ingfully to the overall therapeutic effect.                      designing a treatment program is to identify the type of
                                                                 attentional problems that will be the target of interven-
                                                                 tion. Both the purely cognitive and more social aspects of
           III. EMPIRICAL STUDIES                                attention can be addressed in the remediation program.
                                                                 The procedures available for remediation of attention in-
   The largest and best controlled studies of treatment          clude computerized and noncomputerized exercises that
efficacy indicate a positive effect of attention training.        may be done individually or in groups. Computerized ex-
These effects can be seen both in terms of improved per-         ercises tend to focus on the more purely cognitive aspects
formance on pure measures of (nonsocial) attention               of attention, whereas group exercises often target atten-
and improvement in social and psychological function-            tion as it applies in a social setting.
ing. Patients exposed to computerized attention exer-               Given that attention deficits are not simply a mani-
cises such as the ORM have been shown to improve                 festation of neuropsychological dysfunction, but rather
both on the remediation exercises themselves and on              social–emotional–cognitive dysfunction, remediation
the CPT, an independent measure of ability to focus and          procedures that emphasize an integrated approach to
sustain attention. Noncomputerized attention training            the patient are more likely to appreciate the complex
such as the IPT groups, which offer exercises to improve         interaction of cognitive, emotional, and environmental
attention in social contexts, has also been demonstrated         variables in the recovery process. Attention remedia-
to improve performance on some aspects of pure,                  tion has been found to be effective in improving per-
nonsocial attention. Performance on the Span of Appre-           formance on pure measures of (nonsocial) attention
hension, which requires rapid scanning of stimulus fea-          and social and psychological functioning. Replication
tures, was improved in patients exposed to 6 months              of well-controlled treatment efficacy studies is needed.
intensive IPT training. There is also evidence that com-         Many treatment parameters have yet to be researched,
puterized and noncomputerized attention training im-             for example, optimal intensity and duration of treat-
pacts on social competence and psychological status as           ment, characteristics of treatment responders and non-
measured by such instruments as the AIPSS and BPRS.              responders, and the various contributions of specific
                                                                 and nonspecific treatment effects.
Shaping techniques used in group therapy to improve
social aspects of attention have been found to improve
ability to stay on task as measured in minutes, in small
                                                                         See Also the Following Articles
samples of chronic treatment refractory patients, some
who had low IQ. Well-controlled, large treatment effi-            Differential Attention   I   Neuropsychological Assessment
cacy studies are still rather scarce and replication of re-
sults is required. Many parameters have yet to be
studied, for example, optimal intensity and duration of                             Further Reading
treatment, characteristics of treatment responders and                        .,
                                                                 Green, M. F Kern, R. S., Braff, D., & Minta, J., (2000). Neu-
nonresponders, and optimal balance of focus on social              rocognitive deficits and functional outcome in schizophre-
and nonsocial aspects of attention.                                nia: Are we measuring the “right stuff”?. Schizophrenia
                                                                   Bulletin, 26, 119–136.
                                                                 Hogarty, G. E., & Flesher, S. (1999). Practice principles of
                   IV. SUMMARY                                     cognitive enhancement therapy for schizophrenia. Schizo-
                                                                   phrenia Bulletin, 25, 693–708.
                                                                 Medalia, A., & Revheim, N. (1999). Computer assisted learn-
   Attention impairment is a common symptom of psy-
                                                                   ing in psychiatric rehabilitation. Psychiatric Rehabilitation
chiatric disease. In schizophrenia, attention impairment           Skills, 3, 77–98.
is associated with poor outcome, deficient social skills,         Medalia, A., Aluma, M., Tryon, W., & Merriam, A. E. (1998).
and diminished ability to benefit from rehabilitation and           Effectiveness of attention training in schizophrenia. Schiz-
skills training. The attention system is composed of sub-          ophrenia Bulletin, 24, 147–152.
systems that perform different but interrelated cognitive        Nuechterlein, K. H., & Subotnik, K. L. (1998). The cognitive
functions such as the ability to focus, encode, rapidly            origins of schizophrenia and prospects for intervention. In
process and respond, maintain vigilance, and avoid                 T. Wykes, N. Tarries, & S. Lewis (Eds.), Outcome and inno-
                                                     Attention Training Procedures                                            137
   vation in psychological treatment of schizophrenia (pp.              treatment-refractory individuals with schizophrenia. Psy-
   17–41). New York: John Wiley & Sons.                                 chiatric Rehabilitation Skills, 3, 41–58.
Silverstein, S. M., Valone, C., Jewell, T. C., Corry, R., Nghiem,     Spaulding, W., Reed, D., Sullivan, M., Richardson, C., &
   K., Saytes, M., & Potrude, S. (1999). Integrating shaping            Weiler, M. (1999). Effects of cognitive treatment in psychi-
   and skills training techniques in the treatment of chronic,          atric rehabilitation, 25, 657–676.
                                          Aversion Relief
                                    Paul M. G. Emmelkamp and J. H. Kamphuis
                                                      University of Amsterdam




    I.   Description of Treatment                                       hol dependence, smoking, overeating, obsessive-com-
   II.   Theoretical Bases                                              pulsive behavior, and various forms of deviant sexual
  III.   Empirical Studies                                              behavior. Furthermore, perhaps most controversial,
  IV.    Summary                                                        aversive methods have also been used in patients with
         Further Reading
                                                                        autism and mental retardation.
                                                                           Aversive conditioning is intended to produce a con-
                                                                        ditioned aversion to, for example, drinking or deviant
                            GLOSSARY                                    sexual interest. Aversion therapy includes a variety of
                                                                        specific techniques based on both classical and operant
aversion relief A therapeutic procedure in which the occur-
                                                                        conditioning paradigms. With aversive conditioning in
  rence of desired behavior leads to the cessation of an aver-
  sive stimulus.                                                        alcohol-dependent subjects, a noxious stimulus (un-
aversion therapy A variety of specific techniques based on               conditioned stimulus, UCS) is paired with actual
  both classical and operant conditioning paradigms in-                 drinking (conditioned stimulus, CS) or with visual or
  tended to change maladaptive behavior.                                olfactory cues related to drinking. A variety of aversive
covert sensitization The pairing in imagination of undesired            stimuli have been used, the most popular of which
  behavior with covert negative consequences.                           were electric shock and nausea- or apnea-inducing sub-
negative reinforcement Removal of an aversive stimulus that             stances. Covert sensitization is a variant of aversive con-
  leads to an increase of the future probability of the desired         ditioning wherein images (e.g., of drinking situations
  response.                                                             or of deviant sexual stimuli) are paired with imaginal
punishment A method of behavior control in which an unde-
                                                                        aversive stimuli. It is actually “covert” because neither
  sired response is followed by a noxious stimulus, thus
                                                                        the undesirable stimulus nor the aversive stimulus is
  leading to a reduction of the future probability of the un-
  desired response.                                                     actually presented, but these are presented in imagina-
                                                                        tion only. “Sensitization” refers to the intention to build
                                                                        up an avoidance response to the undesirable stimulus.
                                                                           In aversion relief the subject is enabled to stop the
         I. DESCRIPTION OF TREATMENT                                    aversive stimulus by performing more appropriate be-
                                                                        havior, which will lead to feelings of relief. For example,
   Aversive methods were used widely in the 1960s and                   deviant sexual stimuli (e.g., pictures of nude children)
1970s, but for a variety of reasons these methods are                   may be the UCS followed by the onset of shock (CS),
less accepted today. Aversive methods are used for                      while the cessation of shock is preceded by the appear-
treating maladaptive approach behavior, such as alco-                   ance of pictures of nude adult women. The procedure is


Encyclopedia of Psychotherapy                                                                       Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                          139                                                   All rights reserved.
140                                                    Aversion Relief

intended to condition the pleasant experiences associ-           of the pleasurable situation (e.g., drinking) with an un-
ated with the cessation of shock (aversion relief) to adult      pleasant stimulus (feelings of nausea and vomiting).
females, while the unpleasant experiences associated                The procedure will be illustrated with a case of a
with the onset of shock are conditioned to children.             male alcohol-dependent patient. In this procedure, the
   A classical example of aversion relief therapy in chil-       patient first learns to relax. When he is able to relax, he
dren with autism was presented by Lovaas and his co-             is asked to close his eyes and to visualize very clearly a
workers. Autistic children were asked to approach the            drinking situation. For example, he may be asked to vi-
therapist. If the child did not approach, shock was de-          sualize himself in a pub, looking at a glass full of beer,
livered and continued until an approach was made. Sub-           holding the glass in his hand, and having the glass
sequently, shocks could be avoided by approaching                touch his lips. Then he is asked to imagine that he be-
within 5 seconds of the request. This application of             gins to feel sick to his stomach and that he starts vom-
aversion relief led to a dramatic increase in the approach       iting all over himself and the female bartender. Then he
behavior of autistic children and had maintained its ef-         is told to imagine that he rushes outside, or that when-
fect nine months later without further shocks.                   ever he is tempted to drink but refuses to do so, the
   A common example of aversion relief therapy is the            feeling of nausea goes away and he will feel relieved
application of bitter-tasting substances on the thumb in         and relaxed (aversion relief).
children who engage in thumb- or finger-sucking activ-               It is important to use as many aversive details as pos-
ity. Thumb- or finger-sucking will now lead to a bad              sible. A verbatim account might run as follows: Your
taste, which will stop as soon as the child withdraws            stomach feels rather nauseous. As you look at the glass,
the thumb or finger out of the mouth (aversion relief).           puke comes up into your mouth. As soon as you smell the
   Aversion relief has also been applied in treating anx-        beer, you cannot hold it any longer: you vomit. It goes all
iety disorders by Solyom and colleagues, including ob-           over your hand, and your glass. Snot and mucous comes
sessive compulsive behavior, specific phobias, and               out of your nose, you can see it floating around in the beer.
agoraphobic avoidance. Solyom detailed an aversion               There is an awful smell. As you look at this mess you just
relief procedure in the context of agoraphobic avoid-            can’t help but vomit again and again. The female bar-
ance. Patients were repeatedly guided through audio-             tender gets some on her shirt and pants. You see her
taped self-generated narratives of phobic avoidance.             shocked and disgusted expression. You run out of the bar
The vignettes might be interspersed with short pauses            and you feel better and better.
after which mild electric shocks (ES) were delivered.               The patient is usually asked to repeat the scenes pre-
Patients could terminate the shock by pressing a but-            sented during the therapy sessions a number of times
ton and continuing the taped approach scenario. For a            daily until the next appointment. These scenes can be
particular female patient the narrative was: “I am get-          written on pocket-sized cards. The patient is instructed
ting dressed … 15 sec … ES, button pressed (by patients          to carry these cards and to read these scenes several
to terminate ES) to leave my home, as I am getting pre-          times a day. Furthermore, the patient is also instructed
pared and put my make-up on … 15 sec … ES, button                to use this procedure immediately upon noticing an
pressed, the bell rings … 15 sec … ES button pressed. My         urge to drink. Thus, a lot of in vivo conditioning occurs
heart is beating very fast I answer the bell and my              in actual temptation situations, when the patient ap-
boyfriend comes in, he says … 15 sec … ES button                 plies the procedure in the prescribed manner outside
pressed, let’s go Mary, … 15 sec … ES button pressed, the        the therapist’s office.
party is already on.”
   Covert sensitization might be considered an imagi-
nal variant of aversion relief and is also referred to as                    II. THEORETICAL BASES
aversive imagery. Before the formal treatment by covert
sensitization begins, it is important to gather detailed            Aversion relief procedures are rooted in learning
information concerning the characteristics associated            theory. Decreasing the frequency of a behavior by pre-
with the maladaptive approach behavior to be changed.            senting an aversive stimulus immediately after an
This information is essential in order to develop realis-        inappropriate response is a case of punishment. In-
tic scenes for the patient. Furthermore, some time is            creasing the rate of a behavior by removing aversive
spent in providing the treatment rationale. It is ex-            stimuli contingently following a desired response is
plained that the problem (e.g., drinking) is a strongly          termed negative reinforcement. Escape responses pro-
learned habit that must be unlearned by the association          duce relief from aversive stimuli; this procedure is
                                                      Aversion Relief                                                141
called aversion relief. For example, shock during alco-         zation acted by conditioning, the backward procedure
hol sipping could be avoided or escaped by spitting             should be considerably less effective than one adminis-
out the alcohol. The aversion relief component of the           tering the same conditioned and unconditioned stim-
treatment of alcoholics utilizes a desirable response           uli, in the same number of trials, but in a forward
(e.g., spitting out alcohol) as a potential positive rein-      conditioning paradigm.
forcing stimulus, deriving its positive quality from its
contiguity with escape.
   In covert sensitization, the imagining of an aversive                   III. EMPIRICAL STUDIES
situation (e.g., vomiting) as soon as the individual has
an urge to perform the undesired behavior (e.g. drink-             Most of the studies attesting to the effectiveness of
ing) is usually considered a punishment procedure: An           aversion relief as a principal treatment have been un-
aversive stimulus is made to follow the inappropriate           controlled case studies. Procedures based on aversion
response to be reduced. According to punishment the-            relief have been successfully applied in specific pho-
ory, response frequency can be expected to decrease             bias, obsessive compulsive behaviors, obesity, aphonia,
when the noxious stimuli are contiguous with that re-           torticollis, writing cramp, transvestism, fetishism, and
sponse. Initially, the aversive stimulus should be pre-         other deviant sexual interests. Results with thumb-
sented on a continuous basis, but later on a partial            sucking are not always positive. Nathan Azrin and his
schedule can be used. The aversion relief part of covert        co-workers compared aversion relief therapy (using a
sensitization can be considered an escape procedure,            bitter-tasting substance) with habit reversal in 32 chil-
which occurs when a particular stimulus terminates              dren with thumbsucking. At three-month followup,
the presentation of a noxious stimulus. Eventually, cues        47% of the habit-reversal children had stopped thumb-
that initially led to urges will gradually become dis-          sucking, compared to 10% of the aversion relief chil-
criminatory stimuli for avoidance behavior.                     dren. These findings suggest that aversion relief may be
   Although there is some evidence that covert sensiti-         of little value in reducing thumbsucking. However, the
zation may lead to a favorable outcome in patients with         parents in the aversion relief therapy were only in-
addictions and deviant sexual interest a number of the-         structed by phone, whereas the therapist saw the habit
oretical issues remain unresolved, which cast doubt on          reversal children and their parents in a single session.
the presumed theoretical underpinnings of covert sen-           Given this methodological flaw, the results must be
sitization. First, although scene presentation in covert        viewed with caution.
sensitization includes aversion relief, the addition of            Much of the research on the effectiveness of aversion
this component to the overall effectiveness of the pro-         relief in anxiety disorder patients comes from research
cedure has not been evaluated. Moreover, Emmelkamp              conducted by L. Solyom and his colleagues. The largest
and Walta found that the effects of covert sensitization        study to date involved 50 phobic patients randomly as-
could better be explained by cognitive factors such as          signed to flooding in imagination, systematic desensiti-
outcome expectancy than by conditioning. In their ex-           zation in imagination, aversion relief, phenelzine, or
perimental study, half of the participants (smokers)            placebo. On psychiatric rating, aversion relief was
were led to believe that they participated in an experi-        found to be more effective than the other methods.
mental study on the physiological effects of imagining          However, results are difficult to interpret since the pa-
smoking scenes, whereas the other half were informed            tients in the aversion relief therapy received twice as
that they received a bonafide treatment. All participants        many therapy sessions (24 sessions) as compared to pa-
were treated with covert sensitization. Only the smok-          tients who received flooding or systematic desensitiza-
ers who expected that they received an effective treat-         tion (12 sessions). In an earlier study by the same
ment showed a significant reduction in smoking rate.             research group, the effects of aversion relief were inves-
Thus, the results of this study suggest that cognitive          tigated in agoraphobics. In this study, overall improve-
factors (i.e., expectancy of improvement) rather than           ment was rather small. Patients rated their main phobia
conditioning factors may account for the positive ef-           as unimproved.
fects achieved with covert sensitization. Others have              Although some uncontrolled case studies suggest
also questioned the conditioning explanation of covert          that aversion relief may be of some value in patients
sensitization, since covert sensitization using backward        with obsessive-compulsive rituals and patients with
conditioning was found to be as effective as covert sen-        pure obsessions, the only controlled study into the ef-
sitization using forward conditioning. If covert sensiti-       fectiveness of aversion relief with obsessive-compulsive
142                                                    Aversion Relief

patients found this treatment to be ineffective. Or, as          consisted of 24 weekly sessions of covert sensitization
Kapche concluded in an earlier review of Aversion Re-            and was followed by “booster” sessions every three
lief Therapy (ART): “While ART does not apparently               months for three years. When assigning 75% reduction
hinder treatment, there is no strong evidence that it is         in covert and overt pedophile behavior as a criterion
beneficial.” Perhaps as a byproduct of the demonstrated           for improvement, 89% of the self-referred and 73% of
effectiveness of exposure in vivo procedures, little inter-      the court-referred subjects were rated as improved.
est has since been shown in evaluating the effectiveness         Several measures showed a slight superiority of re-
of aversion relief in patients with anxiety disorders.           sponse in the self-referred group. Inspection of the po-
   Several studies have evaluated the effects of covert          lice records over a three-year period revealed that the
sensitization among alcoholics, but the findings of               self-referred group had no charges, while the court-re-
most of these studies are difficult to interpret due to se-       ferred group had four charges.
vere methodological limitations. One study provided
some evidence that conditioned nausea could be pro-
duced in a number of alcoholics receiving covert sensi-                             IV. SUMMARY
tization treatment. Approximately 90% of patients who
remained in treatment for at least six covert sensitiza-            Despite its strong empirical basis in learning theory
tion sessions reacted with genuine nausea responses as           and the interest it evoked in the 1970s, few controlled
evidenced by swallowing, muscular tremor, and facial             studies have evaluated the effects of aversion relief ther-
grimacing and occasionally by actual vomiting, but               apies in clinical patients. Although a number of studies
only two-thirds of these subjects developed some de-             have reported successful treatment in a variety of disor-
gree of conditioned nausea. Conditioned nausea was               ders (e.g., alcohol dependence, smoking, overeating,
defined as “nausea arising as a direct consequence of             and anxiety disorders), it should be noted that most re-
the subject’s focusing on pre-ingestive or ingestive con-        ports involved (a series of) case studies. Apparently, the
comitants of typical drinking scenes.” Significant de-            literature on aversion relief dried up in the early 1980s:
grees of extended abstinence were observed for                   A Psychinfo literature search revealed no new references
conditioned nausea subjects as opposed to other partic-          in the 1990s, 7 references in the 1980s, and 18 and 5 ar-
ipants. Another well-controlled study found covert               ticles in the 1970s and 1960s, respectively. This does
sensitization more effective than insight-oriented ther-         not specifically concern aversion relief as such but in-
apy and routine milieu treatment in alcohol-dependent            volves nearly all aversive methods. Apparently, only
inpatients. In both studies, participants were inpatients        covert sensitization has not gone totally out of fashion.
in a traditional alcoholism rehabilitation program.                 One of the main reasons behind the absence of re-
Thus, conclusions with respect to covert sensitization           cent controlled research into the effects of aversion re-
as a primary form of treatment are not warranted.                lief procedures may be that aversive stimulation has
   A number of studies have been reported that used              become an increasingly controversial ethical issue.
covert sensitization to reduce deviant sexual interest,          Some have argued that aversive methods are justified
primarily exhibitionists. The largest series (n = 155)           only when the behavior is seriously dangerous to the
was reported by Barry Maletzky, which included a fol-            individual and when no alternative treatment options
lowup ranging from one to nine years. Generally, re-             are available. Internationally, many institutions no
sults of covert sensitization were positive, but a               longer allow aversive methods. In addition, in most in-
number of issues preclude more definite conclusions.              stitutions it is current practice to require that aversive
For example, in the Maletzky studies, about half of the          methods using electric shock obtain prior approval by
exhibitionists received other procedures in addition to          the human rights committee. To be approved, one typi-
covert sensitization. Moreover, these studies did not in-        cally needs to demonstrate that (1) alternative treat-
clude control groups, and progress was evaluated by              ment options have failed or are unjustified, (2) the
means of self-report only. Furthermore, there is some            client (or parents) has given informed consent, and (3)
support in a number of controlled case studies for the           colleagues have approved this technique as profession-
effectiveness of covert sensitization in pedophilic child        ally justified.
offenders, but controlled group studies have not yet                Interest in aversion relief therapy may also have
been reported. Maletzky addressed the issue of whether           waned because alternative (and less intrusive/objec-
there is a difference in outcome between self-referred           tionable) treatments have been found to be at least as
and court-referred pedophiliacs (n = 38). Treatment              effective. For example, in the area of anxiety disorders
                                                      Aversion Relief                                                    143
in vivo exposure methods are now considered the gold                            .
                                                                Emmelkamp, P M. G. (1994). Behavior therapy with adults.
standard, and there is little reason to believe that aver-         In A. Bergin & S. Garfield (Eds.) Handbook of psychother-
sion relief therapy will be able to surpass the effects            apy & behavior change (pp. 379–427). New York: Wiley.
achieved with exposure therapy. Similarly, in the area of                       .
                                                                Emmelkamp, P M. G., & Walta, C. (1978). The effects of
                                                                   therapy-set on electrical aversion therapy and covert sensi-
alcohol dependence, alternative cognitive behavioral
                                                                   tization. Behavior Therapy, 9, 185–188.
procedures (e.g., motivational interviewing, coping
                                                                Kapche, R. (1974). Aversion-relief therapy: A review of current
skills training, and relapse prevention) have been de-             procedures and the clinical and experimental evidence. Psy-
veloped and evaluated in large multicenter trials, such            chotherapy: Theory, research and practice, 11(2), 156–162.
as the MATCH project.                                                                             .
                                                                Lichstein, K. L., & Hung, J. H. F (1980). Covert sensitization:
                                                                   An examination of covert and overt paramters. Behavioral
                                                                   Engineering, 6, 1–18.
       See Also the Following Articles                          Maletzky, B. M. (1991). Treating the sexual offender. Newbury
                                                                   Park, CA: Sage.
Anxiety Management Training I Assisted Covert
                                                                Sheldon, J., & Risley, T. R. (1990). Balancing clients’ rights.
Sensitization I Avoidance Training I Covert Reinforcer
                                                                   The establishment of human-rights and peer-review com-
Sampling I Matching Patients to Alcoholism Treatment I
                                                                   mittees. In A. S. Bellack, M. Hersen, & A. E. Kazdin (Eds.),
Negative Reinforcement I Sex Therapy
                                                                   International handbook of behavior modification and therapy
                                                                   (pp. 227–250). New York: Plenum.
                                                                Solyom, L. (1971). A comparative study of aversion relief and
                 Further Reading                                   systematic desensitization in the treatment of phobias.
Azrin, N. H., Nunn, R. G., & Frantz-Renshaw, S. (1980).            British Journal of Psychiatry, 119(550), 299–303.
  Habit reversal treatment of thumbsucking. Behaviour Re-       Solyom, L. (1972). Variables in the aversion relief therapy of
  search & Therapy, 18, 395–399.                                   phobics. Behavior Therapy, 3(1), 21–28.
                                    Avoidance Training
                                                   James K. Luiselli
                                         The May Institute Inc., Norwood, Massachusetts




    I.   Description of Treatment                                          I. DESCRIPTION OF TREATMENT
   II.   Theoretical Bases
  III.   Empirical Studies                                               An understanding of avoidance training can be
  IV.    Summary
                                                                      gleaned from the following “everyday life” example.
         Further Reading
                                                                      Motorists frequently exceed the speed limits posted on
                                                                      our highways. If a driver in such a situation sees a
                                                                      blinking light ahead and determines that it is a police
                            GLOSSARY
                                                                      vehicle, the driver responds by reducing speed and
avoidance-responding Behavior that postpones (prevents)
                                                                      conforming to the specified limit. In this example, the
   contact with an unpleasant consequence event.                      driver’s behavior of slowing down avoids a possible en-
escape-responding Behavior that terminates ongoing contact            counter with law enforcement that, in turn, leads to a
   with unpleasant stimulation.                                       negative consequence (receipt of a speeding ticket). Re-
negative reinforcement An increase in behavior as a result of         sponding occurs in this way because the driver may
   terminating or postponing an unpleasant stimulation or             have previously been stopped by police or may have
   consequence event.                                                 observed such activity with other motorists. As de-
                                                                      scribed subsequently, this description includes all of
                                                                      the components integral to avoidance training.
                                                                         When implemented for therapeutic purposes, avoid-
   Avoidance training is an intervention approach used                ance training follows a five-step process: (1) identifying
with children and adults that incorporates nonpre-                    the problem behavior to be reduced, (2) selecting a re-
ferred and unpleasant consequences to treat behavior                  sponse to serve as replacement for the problem behav-
disorders. Individuals are taught to refrain from prob-               ior, (3) choosing a negative consequence, (4) pairing
lem responses or to demonstrate acceptable alternative                the negative consequence with the problem behavior,
responses by avoiding contact with the nonpreferred                   and (5) allowing the child or adult to avoid the nega-
and unpleasant consequences. This entry reviews the                   tive consequence. A more detailed description of each
conceptual foundations of avoidance training, use of                  step follows.
the procedure in clinical psychology, and supportive re-                 Behaviors that are the target of avoidance training
search findings.                                                       usually are those that interfere with personal well-




Encyclopedia of Psychotherapy                                                                    Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                        145                                                  All rights reserved.
146                                                   Avoidance Training

being, social adjustment, school performance, occupa-             tacted. The contiguous pairing of behavior and conse-
tional functioning, and the like. Thus, a child may               quence allows the individual to learn the avoidance
show extreme noncompliance with parental requests,                function that is intended to promote alternative re-
or an adult may argue excessively with co-workers.                sponses. Repeated trials usually are programmed to
However, skill deficits also are addressed through                hasten learning effects. It should be noted, however,
avoidance training. A child, for example, may have a              that informing an individual about the relationship be-
health-compromising condition because she or he has a             tween behavior and the negative consequence may also
chronic problem of eating a very limited amount of                produce a desirable outcome. In this situation, the neg-
food. Here the issue is not the presence of a specified            ative consequence is not experienced directly, and con-
“challenging” behavior but instead the absence of a               trolling effects are achieved through verbal mediation
skill. In most cases, simultaneous elimination of a               (i.e., the individual is told “what will happen”).
problem and acquisition of a replacement behavior is                 The final step is the continued exposure of the indi-
the objective of avoidance training.                              vidual to conditions where the negative consequence is
   The issue of a skill deficit is most relevant to step 2 in      avoided following the demonstration of the alternative
the avoidance training paradigm: the selection of a re-           behavior. The objective here is to maintain clinical im-
placement behavior. Recall that a primary objective of            provement for an extended duration.
avoidance training is to strengthen one or more re-                  The following illustration depicts how the five steps
sponses that can substitute for the problem. However,             in an avoidance training protocol would be instituted.
one must determine whether the replacement behavior               The example is a school-age child who exhibits disrup-
is a skill that the child or adult possesses but does not         tive behaviors in the classroom such as talking out of
perform regularly or is a skill that the child or adult has       turn, annoying other students, and using materials to
not learned. Failure to demonstrate a skill that is within        make noise. Because of these behaviors, the child does
a person’s repertoire is a difficulty with performance.            not complete academic assignments. The classroom
Not using a skill because it has not yet been learned is a        teacher determines that one way to reduce these inter-
difficulty with acquisition. Accordingly, how a skill              fering behaviors is to require the child to complete all
deficit is manifested will have implications for whether           assignments in order to participate in daily recess peri-
avoidance training is warranted as intervention and, if           ods. If motivated to complete the assignments, it is
so, what the replacement behavior should be.                      likely that the problem behaviors will decrease. This
   The third step in the process of avoidance training is         depiction qualifies as avoidance training because the
to choose a negative consequence that eventually will             undesirable consequence of not having recess can be
be paired with the display of the problem behavior or             avoided when the child completes academic assign-
the absence of the requisite skill. A negative conse-             ments. The child learns this contingency when she or
quence is unpleasant and produces distress for the indi-          he experiences the loss of recess because of incomplete
vidual. For this reason, certain ethical and clinical             performance. Or, to reiterate a previous point, simply
concerns must be embraced when considering avoid-                 informing the child about the conditions governing
ance training. During the 1960s and 1970s, many publi-            participation in recess may be sufficient to produce the
cations in the behavior modification and behavior                 behavior objective
therapy literature described avoidance training applica-
tions that relied on “noxious” (aversive) types of stimu-
lation such as electric shock, distasteful solutions, and                    II. THEORETICAL BASES
foul odors. These stimuli are highly invasive and, over
time, have fallen out of favor with behavioral practition-           The theoretical foundation of avoidance training
ers. As revealed in the subsequent section on empirical           rests with the concept of negative reinforcement. Rein-
studies, the “later generation” research concerning               forcement principles form the basis of operant learning
avoidance training typically has incorporated negative            theory that is commonly associated with the research
consequences that are less restrictive and intrusive.                                 .
                                                                  and writings of B.F Skinner. Positive reinforcement is
Nevertheless, these interventions expose individuals to           the presentation of a pleasurable consequence follow-
unpleasant conditions and, therefore, must be selected            ing a behavior, with the result that the frequency of the
and formulated cautiously.                                        behavior increases over time. By contrast, negative re-
   Step 4 of avoidance training is to implement the con-          inforcement is the removal or postponement of a non-
tingency in which the negative consequence is con-                pleasurable consequence following a behavior. Negative
                                                   Avoidance Training                                               147
reinforcement has the same objective as positive rein-         signal,” and if the rat exhibited a specific behavior dur-
forcement, which is to increase behaviors that are ap-         ing the time between the onset of the signal and the
propriate, useful, and functional for an individual.           noxious stimulation, the electric shock would be pre-
With negative reinforcement, the removal or postpone-          vented. The behavior of the rat is “discriminated” be-
ment of undesirable consequences is an effect that is          cause it does not occur in the absence of the signal.
“pleasurable” to the individual and makes it more              This acquisition of discriminated avoidance with lower
likely that the behavior producing that effect will occur      animals serves as an analog for avoidance training ap-
more frequently.                                               plications with humans.
   Negative reinforcement can operate in two ways. In
one instance, a behavior can occur that terminates or
reduces the intensity of ongoing stimulation that is un-                  III. EMPIRICAL STUDIES
pleasant. The behavior would be described as “escape.”
With the second operation, a behavior can postpone or             As a preview to the presentation of research concern-
prevent the unpleasant stimulation and would be de-            ing avoidance training with children and adults, several
scribed as “avoidance.” Escape responding, therefore,          considerations should be the focus of attention. First,
requires that behavior be demonstrated in the presence         in contrast to other procedures within behavior modifi-
of the unpleasant (negative) stimulation, whereas              cation and behavior therapy, there has been less em-
avoidance responding occurs in the absence of the un-          phasis on avoidance training as a first-line strategy to
pleasant (negative) stimulation.                               clinical intervention. This fact likely results from the
   On a clinical level, the distinction between escape-        requirement that unpleasant consequences must be in-
generated and avoidance-generated behavior is an im-           corporated when programming avoidance training. For
portant one because it is defined by the presence or            many professionals, it is unpalatable to add distress to
absence of negative conditions. Imagine an adolescent          the life of a child or adult who already is experiencing
boy in a psychiatric hospital who is confined to a room         adjustment difficulties. Even in cases where avoidance
(seclusion) because he becomes “out of control” on the         training may be clinically justified, it can be an arduous
inpatient unit. Being in the room is unpleasant for the        task arranging the conditions wherein negative conse-
boy, and he learns that this condition can be terminated       quences are arranged contiguously with behavior or are
by being released from the room when he composes               introduced within everyday settings.
himself. Regaining his control is reinforced negatively           A second issue is that where avoidance training has
because it allows him to escape a contemporaneous,             been supported by empirical research, the procedure
unpleasant condition. Learning by avoidance would be           frequently is combined with other treatment methods.
evident when confinement to the room is not encoun-             It is rare, in fact, to find studies that have not described
tered by the boy because he behaves properly without           such multicomponent intervention. Again, inclusion of
“losing control.” Here, negative reinforcement func-           negative consequences in the therapeutic process dic-
tions because the boy’s desirable behavior prevents            tates that additional (e.g., positive reinforcement) pro-
room confinement.                                               cedures be used.
   Avoidance training can be traced to experimental an-           Finally, the early history of avoidance training in
imal research. Under conditions termed free operant            clinical practice addressed problems, and included cer-
avoidance, electric shocks were delivered automatically        tain negative consequences, that are not consistent
to a rat through a device on the grid floor of a small          with contemporary standards. One example is research
metal chamber. The shocks were programmed to occur             conducted during the 1960s in which children who
at preset intervals via a recycling timer. A second timer      had autism and were not responsive to social interac-
postponed shock onset by a particular duration each            tion were treated through avoidance training with elec-
time the rat pressed a lever. This type of experimenta-        tric shock. A therapist issued the instruction, “Come
tion revealed different patterns of lever-press respond-       here,” and an electric current was passed through the
ing as a function of variables such as shock intensity,        grid floor. The children “escaped” the aversive stimula-
temporal parameters between intervals, and the sched-          tion when they approached the therapist. They then
ule of shock presentations. Related research concerned         learned to avoid the shock by responding quickly to the
the study of “discriminated avoidance” in which a neu-         social instruction.
tral stimulus was programmed to precede electric                  Other research, reported in the 1970s, used electric
shock. The neutral stimulus functioned as a “warning           shock in an avoidance training paradigm to “treat”
148                                                   Avoidance Training

women and men who were homosexual and wished to                      Reference to the literature on child behavior prob-
changed their sexual orientation. The clients viewed              lems reveals that avoidance training has been incorpo-
slides that were projected on a screen and included pic-          rated in many interventions that include contingent
tures of same-sex adults, clothed and nude, that were             effort. Effort procedures require that when an individ-
rated as attractive. Viewing the slides for a fixed dura-          ual exhibits a behavior that disrupts the environment
tion produced an electric shock. The shock could be               or causes property destruction, the effects of such be-
avoided by pressing a switch, which terminated the                havior must be corrected. Thus, children who break
slide, before the predetermined viewing time elapsed.             objects during an episode of agitation must clean up
Another component of this procedure was to have a                 and restore the surroundings to their previous condi-
slide of the opposite sex appear when the preceding               tion. This increased response effort associated with
same-sex slide was removed. This strategy was an at-              cleanings is avoided by refraining from the problem
tempt to build in counterconditioning in which oppo-              behaviors.
site-sex adults would become appealing because they
were paired with the relief (a positive event) experi-
enced when shock was avoided.                                                         IV. SUMMARY
   The preceding examples provide an historical per-
spective from which to view avoidance training, but they             Avoidance training is an approach to clinical inter-
do not represent acceptable, present-day treatments. For          vention that is founded on the principle of negative re-
one, electric shock is extremely invasive stimulation that        inforcement. Children and adults learn to avoid
behavioral psychologists essentially have abandoned and           negative and unpleasant consequences by not exhibit-
ceased to defend as viable treatment. Relative to children        ing problem behaviors or by demonstrating acceptable
with autism and other developmental disabilities, many            alternatives. Avoidance training as a therapeutic proce-
training procedures and effective interventions have              dure can be linked to operant learning theory that was
been validated that do not rely on aversive methods or            studied in the animal laboratory. In contrast to other
subject individuals to painful consequences. As per the           behavior-change procedures, avoidance training is used
description of adult homosexuality, the professional              less frequently in clinical practice. Because the proce-
community no longer judges this form of sexual orienta-           dure requires exposing a child or adult to unpleasant
tion as an illness or pathology. Furthermore, if a homo-          conditions, it must be considered cautiously and imple-
sexual woman or man sought assistance to change her or            mented with great care in those situations where it can
his sexual orientation, avoidance training of the type de-        be justified clinically.
scribed would not be implemented.
   More benign examples of avoidance training can be
found in the treatment literature with children who re-
                                                                           See Also the Following Articles
ceived intervention for feeding disorders. Several stud-          Aversion Relief I Behavioral Weight Control Therapies I
ies have evaluated avoidance training that targeted               Conditioned Reinforcement I Eating Disorders I
chronic food refusal. Children with this problem do not           Electrical Aversion I Negative Reinforcement I Operant
consume food orally or may eat only select food items.            Conditioning
In many cases, the food refusal is volitional in that
there is no physical cause for the behavior. One type of                             Further Reading
intervention in such cases has been to place food on a
utensil, bring the utensil to the child’s lips, instruct the      Iwata, B. A. (1987). Negative reinforcement in applied behav-
child to “take a bite,” and wait several seconds for the             ior analysis: An emerging technology. Journal of Applied Be-
                                                                     havioral Analysis, 20, 361.
child to consume the food. If independent eating does
                                                                  Matson, J. L., & DiLorenzo, T. M. (1984). Punishment and its
not occur, a therapist prompts mouth-opening by gen-                 alternatives. New York: Springer.
tly pushing against the child’s jaw and depositing the            Sidman, M. (1966). Avoidance behavior. In W. K. Honig
food. The physical guidance delivered by the therapist               (Ed.). Operant behavior: Areas of research and application.
functions as mildly unpleasant stimulation that can be               New York: Appleton.
avoided by the child opening his or her mouth after the           Wilson, G. T., & O’Leary, K. D. (1980). Principles of behavior
verbal instruction is given.                                         therapy. Englewood Cliff, NJ: Prentice Hall.
                                               B
                                    Backward Chaining
                                     Douglas W. Woods and Ellen J. Teng
                                                University of Wisconsin-Milwaukee




    I.   Description of Treatment                                      number of other behaviors in individuals with develop-
   II.   Theoretical Basis                                             mental disablities and who are typically developing.
  III.   Empirical Studies                                             This article will present a description of the procedure
  IV.    Summary                                                       along with the theoretical basis and empirical support
         Further Reading
                                                                       for its use.


                            GLOSSARY                                        I. DESCRIPTION OF TREATMENT
chaining Process by which an organism learns an ordered se-               Many human tasks involve a number of simple, but
   quence of behaviors.                                                separate, motor behaviors that when organized into a
discriminative stimulus A stimulus in the presence of which a          specific sequential fashion, produce a desired outcome.
   particular behavior is reinforced.                                  For example, the task of brushing one’s teeth can be
reinforcement A process in which a behavior is followed by
                                                                       broken down into the following simple behaviors:
   the presentation of a stimulus and as a result, produces an
                                                                       picking the toothbrush up, reaching for the tube of
   increase in the future probability of that behavior.
target behavior The behavior of interest, or the behavior to           toothpaste, grasping the tube of toothpaste, putting
   be altered.                                                         paste on the brush, putting the brush in the mouth,
task analysis A step in the backward chaining procedure in             moving the brush back and forth across the teeth, rins-
   which the entire target behavior is broken down into                ing the mouth, and rinsing the toothbrush.
   smaller sequential steps.                                              Even a relatively simple task such as brushing one’s
                                                                       teeth consists of a number of component behaviors
                                                                       (which themselves, could be further broken down) that
                                                                       must be completed in a specific sequence before an ac-
   Backward chaining is a procedure used to establish                  ceptable outcome can be achieved (i.e., clean teeth). In
relatively complex sequences of behaviors in organ-                    most cases, humans learn such sequences of behavior
isms. Although the procedure was originally applied to                 (called chains) without focused instruction. However,
nonhumans, it has been adopted for use with humans.                    in some cases, focused instruction is required as may be
Typically, backward chaining is used to improve the in-                the case for persons with developmental disabilities.
dependent functioning of individuals with develop-                        To aid in establishing chains of behavior in hu-
mental disabilities, but it can also be used to establish a            mans, applied psychologists have borrowed strategies



Encyclopedia of Psychotherapy                                                                     Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                         149                                                  All rights reserved.
150                                                  Backward Chaining

originally designed by basic researchers in the area of         take a bite and should be praised at the same time. After
operant conditioning. Practitioners have adopted                the final behavior in the chain occurs reliably when the
three such strategies including whole-task chaining,            verbal prompt is given, the clinician should begin to
forward chaining, and backward chaining. The focus              train the second-to-last step in the chain.
of this article is on backward chaining.                           When training the second-to-last step, all the steps in
   Backward chaining is implemented in the following            the chain should be completed by the beginning of that
fashion. First, the clinician must identify the chain of in-    step. Continuing with the previous example, in teaching
terest and the target behavior from completing the chain.       the second-to-last step in the chain, the sandwich would
For example, assume that the clinician wishes to train a        be completely made except that the last slice of bread
client with low functioning to make sandwiches. In this         would not be on the sandwich. When training this task,
case, the chain of interest is sandwich making and the          the clinician would again provide the verbal prompt (e.g.,
target behavior would be consuming the sandwich.                “Alice, make a sandwich for yourself.”), model the spe-
   After the target chain and target behavior have been         cific task (putting the last slice on the sandwich) and
identified, the clinician must conduct a task analysis.          complete the remainder of the chain (lifting the sandwich
When doing a task analysis, the clinician breaks the            to the mouth and taking a bite). After the modeling, the
target chain into discrete component behaviors. For ex-         clinician would provide the verbal prompt then physi-
ample, the task analysis of the sandwich-making chain           cally prompt the client to engage in the novel step (i.e.,
may consist of the following components: taking a               putting the last slice of bread on the sandwich), provide
plate out of the cupboard, taking two slices of bread out       praise for doing so, and prompt the completion (if neces-
of the bag, taking the lunch meat and mustard out of            sary) of the remaining steps in the chain.
the refrigerator, putting one slice of bread on the plate,         After the client is reliably implementing the second-
putting the meat on the sandwich, putting the mustard           to-last link followed by the completion of the remain-
on the meat, placing the remaining slice of bread on            der of the chain, the clinician should begin training the
top, and lifting the sandwich to the open mouth.                third-to-last step using the aforementioned procedures.
   Although it clearly can be seen that the aforemen-           This sequence should continue until the client has
tioned task analysis could be broken down into more             learned the entire sequence and can implement the en-
specific behaviors, the level of specificity used in creat-       tire chain contingent on the verbal prompt (e.g., “Alice
ing the task analysis should be matched with the                make a sandwich for yourself.”).
client’s level of functioning. Clients with lower func-
tioning may require a task analysis that breaks the
chain into very simple and specific components,                             II. THEORETICAL BASIS
whereas clients with higher functioning may do well
with a less simplified task analysis.                               Backward chaining was developed by operant learn-
   On completion of the task analysis, the actual chain-        ing researchers to systematically train complex se-
ing procedure begins. In backward chaining, the first be-        quences of behaviors. The term chaining refers to the
havior learned by the client is the last component              way in which the behaviors pertaining to a specific se-
behavior in the chain. On completion of the final behav-         quence are linked together. In backward chaining, the
ior in the chain, the person receives the reinforcer asso-      behaviors are learned in a reverse order from how the
ciated with the outcome of the chain (called the terminal       chain is performed. In other words, the final step in the
reinforcer). In the aforementioned chain, the first behav-       chain is learned first, followed by the next-to-last step
ior learned by the client would be lifting a prepared           and so on. Each link in the behavioral chain is evoked
sandwich to the mouth, and the resulting reinforcing            by a discriminative stimulus and reinforced by the con-
outcome would be consuming a bite of the sandwich. To           sequences of the behavior involved in the link. For ex-
teach the sandwich lifting, the clinician should start by       ample, in early learning studies, a discriminative
providing a verbal prompt to engage in the chain of be-         stimulus (e.g., a red light) was presented to the organ-
havior (e.g., “Alice, make a sandwich for yourself.”) and       ism. If the organism made the correct response (e.g.,
then model the behavior for the client. After the clini-        pressing a lever), food was presented. Not only was the
cian models the behavior, he or she should then provide         lever pressing reinforced, but the red light was also es-
the verbal prompt again followed by a physical prompt           tablished as a reinforcing stimulus. When the operant
for the client do the same behavior. After the client lifts     chamber was rearranged so the organism had to do an-
the sandwich to her mouth, she should be allowed to             other behavior (e.g., wheel running) to produce the red
                                                     Backward Chaining                                               151
light, it soon did so and then completed the chain of           reviewed. Included are brief discussions of variables to
pressing the lever and receiving food. In this case, the        consider when using this technique, such as target popu-
presence of the wheel became a discriminative stimulus          lations and behaviors, treatment outcome variables, and a
for wheel running, which was reinforced by the appear-          comparison of backward chaining to other chaining pro-
ance of the red light. The red light, in turn served as a       cedures, including a brief discussion on when backward
discriminative stimulus for the lever pressing that was         chaining methods should be implemented.
reinforced by the final outcome of food presentation.
   In the applied arena, backward chaining is conceptu-
                                                                              A. Client Populations
alized in a similar fashion. The outcome of the chain is
equivalent to the food received by the non-human or-               Research demonstrates that backward chaining has
ganism in the operant chamber. The discriminative stim-         been successfully used with diverse populations ranging
ulus for the last link in the chain is the situation present    from children to elderly adults. Although some research
immediately prior to engaging in the last behavior. Using       has demonstrated the effectiveness of this procedure
the previous applied example, the discriminative stimu-         with persons who are typically developing the majority
lus would be the completed sandwich lying on a plate            of studies have focused on individuals with developmen-
prior to being picked up. As the clinician moves back-          tal disabilities. Within this latter population, backward
ward to the next step in the chain, the completed sand-         chaining has been extensively used and found to be par-
wich will not only function as a discriminative stimulus        ticularly effective in teaching skills to children and
for picking the sandwich up, but the sight of the com-          adults with mild to profound mental retardation and to
pleted sandwich will function as a reinforcer for the pre-      children with other developmental disorders such as
ceding behavior in the chain (e.g., putting the last piece      autism. It is not clear why research has focused so heav-
of bread on top of the mustard-covered sandwich). This          ily on evaluating backward chaining in persons with de-
process will continue until the original verbal prompt          velopmental disabilities, but it may be the case that
begins to function as the discriminative stimulus that          persons who are typically developing often do not re-
will initiate the entire behavioral chain.                      quire the intensive type of training to establish behavior
   As can be seen from these examples, an individual            sequences as provided by the procedure.
learning a sequence of behavior through backward
chaining repeatedly experiences the effect of the termi-
nal reinforcer presented at the end of the chain as each
                                                                             B. Targeted Behaviors
link is added. This theoretical advantage of backward              Among persons who are typically developing, back-
chaining distinguishes it from other methods of chain-          ward chaining has been effective in treating children
ing such as forward chaining, in which the first step of         with specific speech problems such as misarticulation.
a sequence is taught first and then linked to the second         In 1987, Edna Carter Young used backward chaining as
step and so on, or whole-task chaining, in which all the        part of a procedure to retrain the speech of two toddlers
steps, from start to finish, are attempted on each trial.        who frequently omitted weak syllables or consonants.
In the latter two cases, the terminal reinforcer is not         Essentially, the procedure involved teaching the child
presented until the person has successfully learned all         to say the last part of a word first and then incorporat-
steps in the behavioral chain.                                  ing that part into the word. For example, to learn to say
                                                                the word monkey, the child was first taught to say key,
                                                                and then join it to the rest of the word, mon, thereby
            III. EMPIRICAL STUDIES                              producing the word monkey.
                                                                   Some evidence also suggests that backward chaining
   Backward chaining was first implemented in an oper-           can be an effective teaching method for learning novel
                       .
ant laboratory by B. F Skinner in 1938. After demonstrat-       tasks. For example, in 1990, Daniel W. Ash and Dennis
ing the effectiveness of backward chaining in studies with      H. Holding used backward chaining as one method of
non-human animals, the procedure was first applied to            teaching students without prior musical experience to
humans in an effort to develop more effective instruc-          play different sequences of musical notes on an electric
tional methods in classroom settings. Since then, back-         piano. Likewise, other studies examining the effective-
ward chaining has been applied in diverse settings and          ness of backward chaining methods in flight simulation
found to be effective in teaching specific skills. In this       tasks have demonstrated it to be an effective method in
section, the clinical utility of backward chaining is briefly    teaching various components of aircraft landing.
152                                                  Backward Chaining

   Although the prior examples demonstrate the use of           there is no one set criterion against which to measure
backward chaining with persons who are typically devel-         the effectiveness of a backward chaining procedure. In-
oping the procedure is most commonly used to teach              stead, there are a number of variables that are com-
skills to persons with developmental disabilities. Within       monly used to gauge its effectiveness. In a review of
this population, backward chaining has been widely ap-          chaining techniques by Fred Spooner and colleagues in
plied in teaching various independent living skills to chil-    1984, the major dependent variables of interest include
dren and adults. Examples include hygiene skills such as        (1) time to criterion (predetermined number of suc-
self-grooming, teeth brushing, and toileting, socializa-        cessful performances of entire chain determined by the
tion, and travel skills. For example, in 1979, Barbara Gru-     trainer), (2) number of incorrect responses (steps of
ber and colleagues used backward chaining to teach four         the chain performed incorrectly), (3) number of cor-
institutionalized males with profound retardation to walk       rect responses (steps of the chain performed correctly),
independently from their place of residence to school.          (4) rate of correct responses (number of correctly per-
Such efforts have been instrumental in allowing persons         formed steps of the chain performed in a given period
with developmental disabilities to live in less restrictive     of time), and (5) rate of incorrect responses (number of
environments such as group homes.                               incorrectly performed steps of the chain performed in a
   Not only has backward chaining been used to teach            given period of time).
self-help skills to persons with developmental disabili-           Although there has been some question regarding
ties, it has also been successful in helping children with      how to determine the effectiveness of a training proce-
autism to learn to speak in short sentences. In addition,       dure, variables should be selected based on the goal of
several studies have demonstrated the effectiveness of          the behavior that is being taught. For example, in 1980,
backward chaining in treating children who refuse to            Richard T. Walls and colleagues noted that number of
eat or drink. For example, in 1996, Louis P. Hagopian           errors often serve as the critical measure because errors
and colleagues used backward chaining as part of a pro-         may impede subsequent learning. On the other hand, if
cedure to treat a 12-year-old boy with autism and men-          speed is more important than accuracy in learning the
tal retardation who completely refused liquids. After           behavioral sequence, then rate should be selected as a
obtaining a baseline measure of the boy’s drinking and          measure of outcome effectiveness.
conducting a task analysis, backward chaining was im-
plemented. In this case, drinking water from a cup was
the target response, and the chain consisted of three
                                                                    D. Comparing Backward, Forward,
segments: (1) bringing the cup of water to the mouth,
                                                                        and Whole-Task Chaining
(2) accepting water into the mouth, and (3) swallow-               Comparative research on the effectiveness of the dif-
ing. To implement this backward chain, the boy was              ferent chaining methods has produced mixed results.
first reinforced by being given access to a preferred ac-        Several studies involving individuals with developmen-
tivity for 90 sec when he swallowed after being                 tal disabilities have revealed that forward and backward
prompted to do so, and then he gradually swallowed a            chaining were more effective methods for teaching new
small amount of water from a syringe. In the third step,        skills compared to a whole-task approach. For exam-
he was required to bring a cup containing a small               ple, in 1981 Richard T. Walls and colleagues compared
amount of water to his mouth, accept the water into his         all three chaining methods and found that forward and
mouth, and swallow the water before reinforcement               backward chaining resulted in fewer errors when
was delivered. Using this procedure, Hagopian and col-          teaching adults with moderate retardation to assemble
leagues were able to successfully teach the boy to grad-        objects, compared to the whole-task chaining method.
ually drink an increasing quantity of liquids.                  In this study, there were no significant differences be-
                                                                tween forward and backward methods.
       C. Variables Used to Determine                              On the other hand, in 1983, Fred Spooner and col-
                                                                leagues compared only backward to whole-task
           Outcome Effectiveness
                                                                chaining when teaching adults with profound retar-
  As with most behavioral interventions, the structure          dation to assemble objects and found that whole-task
and goal of an intervention is determined after an as-          chaining required fewer trials to reach criterion than
sessment is conducted. Similarly, depending on the              backward chaining.
goal of the intervention, the way in which its effective-          Research comparing the effectiveness of chaining
ness is measured will vary across situations. Therefore,        methods remains equivocal. However, as Gregory J.
                                                    Backward Chaining                                                  153
Smith suggested in 1999, the mixed results regarding           humans. Although it has also been used with persons
the effectiveness of different chaining methods may be         who are typically developing, it has been predomi-
due to the fact that different populations were used in        nantly applied when teaching basic daily living skills to
various studies, and different types of behaviors were         persons with developmental disabilities. The essential
taught. Therefore, no direct comparisons among chain-          feature of backward chaining is teaching a sequence of
ing methods can be made without first taking these              behaviors in reverse order, starting with the last step in
variables into account.                                        the behavioral sequence. Although it is unclear if back-
   Similarly, as a review of the research suggests, there      ward chaining is more effective than other chaining
does not seem to be one method that is more effective          procedures, one advantage of backward chaining is that
than the others across all situations, rather, it is more      the terminal reinforcer is always delivered as the indi-
probable that the effectiveness of the chaining method         vidual completes each step.
used is dependent on several factors, including variables
associated with the learner (such as level of cognitive
                                                                        See Also the Following Articles
functioning) and the type of behavior being taught.
Therefore, when deciding which chaining methods to             Behavior Therapy: Historical Perspective and Overview    I
use, clinicians should consider their client’s level of in-    Chaining I Classical Conditioning I Conditioned
telligence and the type of behavior being taught.              Reinforcement I Forward Chaining I Home-Based
                                                               Reinforcement I Operant Conditioning

        E. When Backward Chaining
           Should Be Implemented                                                 Further Reading
                                                               Ash, D. W., & Holding, D. H. (1990). Backward versus for-
   In general, the backward chaining method has been             ward chaining in the acquisition of a keyboard skill.
found to be effective and most appropriate for use with          Human Factors, 32(2), 139–146.
individuals with cognitively lower functioning includ-         Gruber, B., Reeser, R., & Reid, D. H. (1979). Providing a less
ing persons with developmental disabilities. However, it         restrictive environment for profoundly retarded persons by
is also appropriate to use with individuals with higher          teaching independent walking skills. Journal of Applied Be-
functioning when a behavior is more complex and diffi-            havior Analysis, 12, 285–297.
cult, often involving many steps. In this case, backward                      .,
                                                               Hagopian, L. P Farrell, D. A., & Amari, A. (1996). Treating
chaining may be preferred over a whole-task approach             total liquid refusal with backward chaining and fading.
because it can be particularly effective in teaching the         Journal of Applied Behavior Analysis, 29, 573–575.
person one component of the behavioral sequence at a           Smith, G. (1999). Teaching a long sequence of behavior using
                                                                 whole task training, forward chaining, and backward
time, before attempting to chain all the components to-
                                                                 chaining. Perceptual and Motor Skills, 89, 951–965.
gether. Furthermore, backward chaining may be more                        .
                                                               Spooner, F (1984). Comparisons of backward chaining and
effective than other chaining methods in situations              total task presentation in training severely handicapped
when client motivation is low or when a response is in-          persons. Education and Training of the Mentally Retarded,
frequent or absent, because other chaining methods will          19(1), 15–22.
limit the client’s access to the terminal reinforcer.                     .,
                                                               Spooner, F & Spooner, D. (1984). A review of chaining tech-
                                                                 niques: Implications for future research and practice. Edu-
                                                                 cation and Training of the Mentally Retarded, 19, 114–124.
                                                                          .,
                                                               Spooner, F Weber, L. H., & Spooner, D. (1983). The effects
                   IV. SUMMARY                                   of backward chaining and total task presentation on the
                                                                 acquisition of complex tasks by severely retarded adoles-
  Generally, backward chaining is an effective tech-             cents and adults. Education and Treatment of Children, 6(4),
nique used to teach a complex sequence of behaviors to           401–420.
                                Beck Therapy Approach
                                                           Judith S. Beck
                                Beck Institute for Cognitive Therapy and Research, University of Pennsylvania




    I.   Description of Treatment                                         be time limited, problem solving oriented, and struc-
   II.   Theoretical Basis                                                tured. Both patient and therapist are quite active. The
  III.   Efficacy                                                          treatment emphasizes having patients learn to identify
  IV.    Summary                                                          and modify their distorted or dysfunctional thoughts
         Further Reading
                                                                          and beliefs and to change their dysfunctional behavior.
                                                                          In doing so, patients’ mood, symptoms, functioning,
                                                                          and relationships improve.
                            GLOSSARY
automatic thought An idea that seems to arise in one’s mind                    I. DESCRIPTION OF TREATMENT
   spontaneously, in verbal or imaginal from.
belief One’s basic understandings of oneself, one’s world, and
                                                                             Cognitive therapy is based on the cognitive model
   other people.
                                                                          that describes the relationship between people’s percep-
cognition A thought, image, rule, attitude, assumption, or
   belief.                                                                tions and interpretations of situations and their reac-
cognitive distortion A type of thinking error.                            tions (emotional, behavioral, and physiological). When
schema A relatively stable and enduring mental structure                  people are in distress, their thinking is often character-
   that exerts a significant influence over one’s processing of             ized by faulty information processing; their perceptions
   information.                                                           are often invalid, or not completely valid. For example,
                                                                          a depressed woman makes only two mistakes when
                                                                          word processing a long document at work and thinks,
                                                                          “I can’t do anything right.” This thought is called an
   Cognitive therapy is a system of psychotherapy,                        “automatic thought,” because it seems to pop up spon-
based on a comprehensive theory of psychopathology                        taneously in her mind. Before therapy, she may have
and personality. Its theoretical underpinnings have                       been only vaguely aware of these kinds of thoughts, if
been empirically supported, and the therapy itself has                    at all. She may have been much more cognizant of her
been demonstrated to be effective in over 325 outcome                     reaction: her affect (sadness), her dysfunctional behav-
studies for a wide range of psychiatric disorders. Treat-                 ior (leaving work early), and/or her physiological re-
ment is based on specific cognitive formulations of                        sponse (heaviness in her body).
each disorder and on the individual cognitive concep-                        In therapy, patients learn to cue themselves when
tualization of each patient. Cognitive therapy tends to                   they notice their negative reactions so they can identify



Encyclopedia of Psychotherapy                                                                           Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                            155                                                     All rights reserved.
156                                               Beck Therapy Approach

their automatic thoughts. Then they learn techniques           disconfirm, or modify their hypotheses. A Cognitive
of evaluating the validity and utility of their thoughts.      Conceptualization Diagram (Figure 1) aids therapists
When they correct their distorted thinking, they have a        in concretely formulating their conceptualization.
more positive reaction: their affect lifts, their behavior     Therapists check out their conceptualization with pa-
becomes more functional, they have an improved phys-           tients to ensure they are on the right track.
iological response. Much of the therapy is organized               A strong therapeutic alliance is an essential part of
around helping patients directly change their thinking         cognitive therapy. Therapists build the alliance by work-
and behavior and solve problems.                               ing collaboratively with the patient as a “team,” demon-
   Treatment varies somewhat from disorder to disorder         strating care, concern, and competence; providing
and patient to patient, though there are several basic         rationales before using various strategies; summarizing
principles described elsewhere by the author.                  patients’ narratives to ensure accurate understanding;
                                                               checking hypotheses and formulations with patients;
1. Cognitive therapy is based on an ever-evolving for-         solving problems; eliciting feedback at the end of ses-
   mulation of patients and their problems according           sions (and during sessions, if they infer a negative reac-
   to a cognitive framework.                                   tion); and helping patients quickly to reduce symptoms.
2. Cognitive therapy requires a sound therapeutic                  It is often more difficult to establish a strong thera-
   alliance.                                                   peutic alliance with patients who have dysfunctional
3. Cognitive therapy emphasizes collaboration and              relationships outside of therapy. They often bring dys-
   active participation..                                      functional beliefs about themselves and other people to
4. Cognitive therapy is goal oriented and initially            the therapy relationship (e.g., “If I trust other people,
   focuses on current problems.                                I’ll get hurt.”). When such a belief interferes with a
5. Cognitive therapy is educative and emphasizes               “standard” approach, therapists help patients elicit,
   relapse prevention.                                         test, and respond to patients’ distorted ideas about the
6. Cognitive therapy aims to be time limited.                  therapist and about therapy.
7. Cognitive therapy sessions are structured.                      Therapists as well as patients are quite active during
8. Cognitive therapy teaches patients to identify,             the therapy session. Therapists continually engage in
   evaluate, and respond to dysfunctional thoughts             Socratic questioning, as they ask patients open-ended
   and beliefs.                                                questions to collect data, elicit key thoughts, uncover
9. Cognitive therapy uses a variety of techniques to           the meaning of their thoughts, identify beliefs, test the
   modify thinking, mood, and behavior.                        evolving conceptualization, and evaluate thoughts and
                                                               beliefs. Collaboration is an important principle of cog-
These principles are described below.                          nitive therapy: therapist and patient work together to
   Cognitive therapists conceptualize patients in cogni-       identify and understand the patient’s problems and per-
tive terms, that is, they seek to understand how patients’     spectives. They collaborate in setting goals, defining
beliefs give rise to specific thoughts in current situations    and solving current problems, and devising tests to as-
and influence their reactions. When patients have long-         sess the accuracy of their thinking.
standing personality problems, therapists also seek to             Initially the focus is on the present, helping patients
understand how patients have historically interpreted          identify and modify their thinking about distressing sit-
events, often since childhood, and how these interpreta-       uations, solving problems, and changing behavior. To-
tions have influenced (and still influence) their ideas          ward the middle of therapy, there is an additional
about themselves, their worlds, and others.                    emphasis on modifying maladaptive beliefs. In the final
   Therapists also identify the maladaptive behavioral         stage of therapy, relapse prevention strategies are em-
“coping” strategies patients develop to get along in the       phasized. In actuality, therapists use relapse prevention
world. For example, a therapist hypothesized that be-          strategies from the beginning of therapy, as they not
cause of genetic predisposition and early abuse, Beth          only help patients change their thinking and behavior
developed the belief that she was bad and defective.           but also instruct patients in how to do so themselves.
Fearful that others would view her negatively, she de-         An important goal of therapy is to teach patients to be-
veloped the coping strategy of always putting on a good        come their own therapists.
face. Otherwise, she believed, people would see her                Cognitive therapy is generally a relatively brief form
“real” self and reject her.                                    of psychotherapy. Most straight-forward depressed and
   Treatment is based on an ever-evolving conceptual-          anxious patients achieve remission with six to twelve
ization as therapists collect additional data to confirm,       sessions of therapy (weekly at first, then spaced further
                                                Beck Therapy Approach                                             157




FIGURE 1 Cognitive Conceptualization Diagram. From Judith Beck, Cognitive Therapy: Basics and Beyond. © Judith S. Beck,
1993. Reprinted with permission of Guilford Press.


apart). Patients with more complex disorders, comor-             Cognitive therapy sessions generally follow a certain
bid diagnoses, severe or chronic symptoms, or person-         structure. At the beginning therapists obtain an objec-
ality pathology may require (sometimes significantly)          tive and subjective account of patients’ symptoms, gen-
longer treatment.                                             eral mood, progress, and behavior in the past week.
158                                               Beck Therapy Approach

They jointly set an initial agenda; patients are asked to      • Environmental: weighing advantages and disadvan-
label the most important problem(s) they want to work            tages of making changes in living or work environ-
on during the session. They make a “bridge” from the             ments (if indicated), responding to thoughts that
previous session, asking patients to recall important            interfere with making needed changes
conclusions from the previous session, significant             • Supportive: demonstrating empathy, regard, caring, ac-
events during the past week, and what they gained or             ceptance, and accurate understanding of patients’ in-
learned from the self-help assignments (“homework”)              ternal reality through verbal and non-verbal responses
they did. They also ask patients whether they predict          • Experiential: roleplaying; using imaginal techniques
any special problems will arise in the coming week.              to respond to automatic thoughts in the form of im-
   This additional data often leads to additional agenda         ages; inducing images to heighten affect (to uncover
items. The agenda is collaboratively prioritized. The            key cognitions) or to reduce affect; restructuring the
session is then organized around the problems on the             meaning of traumatic events through the re-experi-
agenda. Patients and therapists collaboratively decide           ence of key memories in imaginal from in the pres-
which problem to focus on first. In the context of dis-           ence of heightened affect, then using guided
cussing a problem, therapists gather data to refine their         imagery and/or psychodrama techniques
conceptualization and teach patients skills, such as           • Psychodynamic-like: helping patients identify and
identifying and critically evaluating their distorted            evaluate automatic thoughts that arise and dysfunc-
thinking and using behavioral and problem-solving                tional beliefs that become activated during the ther-
techniques. Homework assignments are also generated              apy session, particularly dysfunctional ideas about
by the discussion.                                               the therapist or therapy, then guiding them to gen-
   Before moving on to another problem, therapists ask           eralize what they learned to relationships outside of
patients to summarize their conclusions from the dis-            therapy; drawing connections between beliefs
cussion and ensure that they are likely to do the agreed-        (learned earlier in life and maintained throughout
on assignments. At the end of each session, patients             the patient’s life) and his/her interpretations and re-
summarize the most important points of the session,              actions to current situations
and therapists elicit their feedback about the session.
   Cognitive therapists use many different types of tech-         These techniques, whether they are specifically cog-
niques to modify patients’ thinking, mood and behavior,        nitive in nature or not, result in cognitive change.
including                                                      Much of the therapeutic work in cognitive therapy,
                                                               however, is devoted toward directly identifying and
• Cognitive: identifying, evaluating, and modifying            modifying inaccurate or dysfunctional thoughts and as-
  thoughts, images, and beliefs                                sumptions. Therapists often use a worksheet, the Dys-
• Behavioral: activity monitoring and scheduling,              functional Thought Record (DTR) to help patients record
  skills training, graded tasks, distraction, exposure,        and respond to their thoughts and assumptions in a
  response prevention                                          structured way (Table 1).
• Problem solving: specifying problems, responding                Although DTRs are used with many patients, they
  to automatic thoughts and beliefs that interfere             generally are adapted for (or discussed verbally with)
  with problem solving, brainstorming and choosing             patients who might not be able to grasp them fully. Pa-
  solutions, implementing solutions and evaluating             tients are encouraged to use questions such as the fol-
  outcomes                                                     lowing to help them evaluate and devise alternative
• Emotional: regulation of affect through engaging in          responses to their dysfunctional thinking:
  self-soothing activities, relaxation, controlled
  breathing, distraction, seeking support, reading             • What is the evidence that my automatic thought is
  therapy notes                                                  true? What is the evidence on the other side, that
• Physiological: medication (if indicated), exercise, re-        my automatic thought might not be true, or not
  ducing caffeine and other drugs, focusing externally           completely true?
  instead of internally                                        • What is an alternative explanation or an alternative
• Interpersonal: correcting faulty beliefs, learning com-        viewpoint?
  munication, assertiveness and other social skills, solv-     • What is the worst that could reasonably happen and
  ing interpersonal problems (bringing family members            how would I cope? What is the best that could hap-
  or significant others into therapy, if indicated)               pen? What is the most realistic outcome?
                                                                                       TABLE 1
                                                                             Dysfunctional Thought Record

Directions: When you notice your mood getting worse, ask yourself, “What’s going through my mind right now?” and as soon as possible jot down the thought or mental image in
the Automatic Thought Column.

 Date/time                      Situation                      Automatic thought(s)                   Emotion(s)                      Adaptive response                     Outcome

                     1. What actual event or stream           1. What thought(s)               1. What emotion(s)           1. (optional) What cognitive          1. How much do you
                        of thoughts, or daydreams                and/or image(s) went             (sad/anxious/                distortion did you make?              now believe each
                        or recollection led to the               through your mind?               angry/etc.) did you       2. Use questions at bottom to            automatic thought?
                        unpleasant emotion?                   2. How much did you                 feel at the time?            compose a response to the          2. What emotion(s)
                     2. What (if any) distressing                believe each one              2. How intense                  automatic thought(s).                 do you feel now?
                        physical sensations                       at the time?                    (0–100%) was the          3. How much do you believe               How intense (0–100%)
                        did you have?                                                              emotion?                    each response?                        is the emotion?
                                                                                                                                                                  3. What will you do
                                                                                                                                                                     (or did you do)?

 Friday, 2/23        Talking on the phone                     She must not like                 Sad 80%
   10 A.M.             with Donna.                              me any more. 90%

 Tuesday, 2/27       Studying for my exam.                    I’ll never learn                 Sad 95%
   12 P.M.                                                        this. 100%

 Thursday, 2/29      Thinking about my economics              I might get called on            Anxious 80%
   5P.M.               class tomorrow.                           and I won’t give a
                                                                 good answer. 80%

                     Noticing my heart beating fast           What’s wrong with me?            Anxious 80%
                       and my trouble concentrating.

    Questions to help compose an alternative response: (1) What is the evidence that the automatic thought is true? Not true? (2) Is there an alternative explanation? (3) What’s the worst that
could happen? What could I do to cope? What’s the best that could happen? What’s the most realistic outcome? (4) What’s the effect of my believing the automatic thought? What could be the
effect of changing my thinking? (5) What should I do about it? (6) If (friend’s name) was in the situation and had this thought, what would I tell him or her?
    From Judith Beck Cognitive Therapy: Basics and Beyond. © Judith S. Beck, 1995. Reprinted with permission of Guilford Press.
160                                                      Beck Therapy Approach

                                                                TABLE 2
                                                        Typical Thinking Errors

Cognitive distortions

 1. All-or-nothing thinking (also called black-and-white, polarized, or dichotomous thinking): You view a situation in only two
    categories instead of on a continuum.
    Example: “If I’m not a total success, I’m a failure.”
 2. Catastrophizing (also called fortune telling): You predict the future negatively without considering other, more likely outcomes.
    Example: “I’ll be so upset, I won’t be able to function at all.”
 3. Disqualifying or discounting the positive: You unreasonably tell yourself that positive experiences, deeds, or qualities do not count.
    Example: “I did that project well, but that doesn’t mean I’m competent; I just got lucky.”
 4. Emotional reasoning: You think something must be true because you “feel” (actually believe) it so strongly, ignoring or dis-
    counting evidence to the contrary.
    Example: “I know I do a lot of things okay at work, but I still feel like I’m a failure.”
 5. Labeling: You put a fixed, global label on yourself or others without considering that the evidence might more reasonably
    lead to a less disastrous conclusion.
    Example: “I’m a loser.” “He’s no good.”
 6. Magnification/minimization: When you evaluate yourself, another person, or a situation, you unreasonably magnify the nega-
    tive and/or minimize the positive.
    Example: “Getting a mediocre evaluation proves how inadequate I am. Getting high marks doesn’t mean I’m smart.”
 7. Mental filter (also called selective abstraction): You pay undue attention to one negative detail instead of seeing the whole picture.
    Example: “Because I got one low rating on my evaluation [which also contained several high ratings] it means I’m doing
    a lousy job.”
 8. Mind reading: You believe you know what others are thinking, failing to consider other, more likely possibilities.
    Example: “He’s thinking that I don’t know the first thing about this project.”
 9. Overgeneralization: You make a sweeping negative conclusion that goes far beyond the current situation.
    Example: “[Because I felt uncomfortable at the meeting] I don’t have what it takes to make friends.”
10. Personalization: You believe others are behaving negatively because of you, without considering more plausible explanations
    for their behavior.
    Example: “The repairman was curt to me because I did something wrong.”
11. “Should” and “must” statements (also called imperatives): You have a precise, fixed idea of how you or others should behave,
    and you overestimate how bad it is that these expectations are not met.
    Example: “It’s terrible that I made a mistake. I should always do my best.”
12. Tunnel vision: You only see the negative aspects of a situation.
    Example: “My son’s teacher can’t do anything right. He’s critical and insensitive and lousy at teaching.”

   From Judith Beck, Cognitive Therapy: Basics and Beyond. Adapted with permission from Aaron T. Beck. Reprinted with permission of Guilford
Press.



• What is the effect of my believing this automatic                      I’m a failure.”), mind reading (“They [his co-workers] are
  thought? What could be the beneficial effects of                        probably laughing behind my back.”), fortune telling
  changing my thinking?                                                  (“I’ll never catch up.”) and labelling (“I’m a total loser.”)
• If [name of specific close friend or family member]                        Other techniques used to help patients evaluate their
  were in this situation and had this thought, what                      automatic thoughts include:
  would I tell him or her?
• What should I do now?                                                  • behavioral experiments (where patients directly test
                                                                           thoughts or assumptions such as, “If I try to get
   Teaching patients to identify their typical cognitive dis-              more done, I’ll just fail.”)
tortions, or types of thinking errors, also helps them un-               • imagery work (using imagery techniques in re-
derstand the relative invalidity of many of their negative                 sponse to spontaneous, negative images)
thoughts (Table 2). When emotionally distressed, people                  • coping cards (collaboratively composing statements,
tend to make many more errors in their interpretations of                  graphics, or pictures for patients to read during the
events than usual. Matthew, for example, consistently                      week to remind themselves of important learnings
displayed all-or-nothing thinking (“Either I’m the best or                 from previous sessions)
                                                    Beck Therapy Approach                                             161
   After patients learn the skill of modifying their auto-       (more accurate and functional) perspectives of negatively
matic thoughts, therapists start emphasizing their cogni-        perceived events and to become aware of, and process
tions at the belief level. An intermediate level of belief       without discounting, positive data and events.
contains attitudes, rules, and assumptions that may have            Other methods for the modification of core beliefs
been understood, but unexpressed, before therapy. Ther-          about the self are the use of extreme contrasts (“How
apists often seek to understand patients’ intermediate be-       much of a failure are you compared to [a specific per-
liefs in assumption form. For example, Peter had a               son whom the patient sees as an extreme failure]?”),
dysfunctional attitude, “It’s terrible to make a mistake.”       metaphors, and cognitive continua (which help pa-
His rule was, “I can’t make mistakes.” His assumption,           tients see that their beliefs are at an extreme, instead of
which was more easily subject to a behavioral test was,          on a continuum). Therapists may help patients recall
“If I make a mistake, terrible things will happen.”              childhood events from which their core beliefs arose
   Core beliefs are a deeper level cognition. They are           (or through which their beliefs became strengthened)
rigid, overgeneralized, global, dysfunctional, and               and then evaluate the validity of those beliefs at that
largely inaccurate understandings that people have of            time and at the current time. This process allows pa-
themselves, their worlds, and other people, such as “I           tients to restructure the meaning of important child-
am unlovable,” “I am helpless,” “Other people will hurt          hood or adolescent experiences at an intellectual level.
me,” “The world is a hostile place.”                             They may need experiential techniques to restructure
   Key dysfunctional beliefs can be identified in several         the meaning at an “emotional” or “gut” level.
ways. Sometimes patients (especially depressed pa-
tients) express their beliefs directly, as automatic
thoughts (“I’m a complete failure.”) Beliefs may be in-                      II. THEORETICAL BASIS
ferred by examining the consistent themes in automatic
thoughts across situations. Cynthia, for example, had               Beck originally based his cognitive treatment for de-
frequent thoughts such as, “Mary won’t want to spend             pression on his cognitive theory of depression that has
time with me,” “No one will want to talk to me at the            been largely supported in hundreds of subsequent
party,” “My friends don’t really know me very well,” “If         studies. Cognitive theory posits that people tend to
I try to get closer to Jane, she’ll reject me,” and “People      perceive and interpret situations in characteristic ways
don’t seem to like me much.” One of Cynthia’s central            that color their feelings and shape their behavior. Peo-
beliefs, expressed indirectly in the thoughts above, was         ple often have spontaneous “automatic thoughts”
that she was unlovable.                                          about their past, current, or future situations. Because
   A third way to uncover beliefs is to ask patients the         automatic thoughts are generally “silent,” people are
meaning of their typical automatic thoughts: “If this au-        more apt to be aware of their subsequent emotions, be-
tomatic thought is true,…                                        havior, or physiological reactions. Automatic thoughts
                                                                 are often fleeting, sometimes telegraphic in nature, and,
• what does that mean?                                           when recognized, highly plausible to the individual—
• what’s the worst part about it?                                even when incorrect or dysfunctional. When people are
• what does it say about you as a person?                        in emotional distress, their thinking becomes more
                                                                 rigid, primitive, and distorted. They make characteris-
   Many of the techniques used to help patients evaluate         tic errors, or cognitive distortions, and may begin to ru-
their automatic thoughts can be used to evaluate core be-        minate or obsess.
liefs as well. Before working on belief modification, how-           At a deeper level, when people are emotionally dis-
ever, therapists present an explanatory model to patients,       tressed, their maladaptive beliefs (their basic under-
so they can better understand why they are absolutely            standings of themselves, their worlds, and other
convinced of the validity of a belief, even though the be-       people) become activated. These beliefs influence their
lief may be inaccurate or largely inaccurate. An informa-        perception and interpretation of their experience. Indi-
tion processing model helps them understand how and              viduals may being to develop a preponderance of nega-
why they easily assimilate data confirming their core be-         tive thinking.
lief but ignore or discount positive data that disconfirm            Beliefs are ideas embedded in mental structures in the
their belief. Patients learn, with their therapists’ help, to    mind called “schemas.” Relatively adaptive schemas may
bring this kind of information processing under con-             predominate when people are not distressed. When they
scious control. Much of the therapy from this point on is        develop a psychiatric disorder, however, their negative
directed toward helping patients develop alternative             cognitive schemas, which may have been dormant or
162                                               Beck Therapy Approach

latent, start to dominate and influence their thinking. A       tive beliefs of inadequacy and failure that led to in-
particular “mode” (composed of a network of interre-           creasingly negative and dysfunctional thinking that led
lated cognitive, affective, motivational, and behavioral       to a deteriorating mood and more dysfunctional behav-
schemas) may become activated and profoundly affect            ior, in an escalating downward spiral.
individuals’ thinking, motivation, mood, and behavior.            Beck and colleagues have developed specific cogni-
The mode represents the constellations at the core of          tive formulations for the major psychiatric disorders.
full-blown disorders such as depression or paranoia.           Depression, for example, is characterized by negative
   How do people develop negative beliefs? These basic         thoughts about the self, experience, and future (“I’m
rules, formulas, and concepts are influenced by genetic         worthless, the world presents too many obstacles, I’ll
predisposition and develop in response to environmen-          always be a basket case.”). Anxious patients’ thoughts
tal events. A child who is verbally abused at school, for      reflect overestimations of threat and underestimations
example, may start to believe that she is unlikable. If        of resources (“It’s very likely terrible things will happen
she has supportive parents, however, her belief may be         and I won’t be able to cope.”). Patients with panic dis-
tempered, and she may see herself as predominately             order make catastrophic misinterpretations of physio-
likeable. If, in her twenties, though, she is rejected by a    logical or mental sensations (“This unreal feeling in my
significant other, her latent belief of unlikability may        head means I’m going crazy.”). Obsessive-compulsive
become activated again, and she may be vulnerable to           patients make misinterpretations of their negative
developing a depressive disorder.                              thoughts and images (“My imagining that I will stab
   Cognitive theory posits a diathesis-stress model to         my friend with this knife means I’m out of control. I re-
explain the occurrence of emotional disorders. Individ-        ally might harm her.”). Hypomanic patients have an in-
uals may be relatively psychologically healthy until a         flated view of themselves and their future (“I am so
congruent stressor activates their dysfunctional beliefs.      powerful, I can do anything I want.”).
These beliefs start to bias how they process informa-             Specific beliefs for each personality disorder have also
tion. People who have relatively strong autonomous             been identified. Patients with dependent personality dis-
personalities, for example, are usually adversely af-          order, for example, believe they are weak and helpless
fected when their efficacy, freedom, or mobility is             and others are strong. Paranoid patients believe other
threatened or reduced. If they are not also high in so-        people are potentially dangerous and that they could be
ciotropy, however, they may be relatively less affected        harmed if they are not watchful. Avoidant patients be-
by interpersonal disruption or loss (and vice versa).          lieve they are defective and others will reject them.
   Joe, for example, was relatively well-adjusted until           These kinds of negative, global, rigid beliefs may have
three stressors occurred. In the first semester of his sen-     originated in childhood or adolescence in people with
ior year in high school, he began to have difficulty in         long-standing problems, and their beliefs may be more
one of his courses, he was dropped by his school’s var-        or less continuously activated. Typically, they develop
sity basketball team, and he started a challenging and         certain guidelines or rules to help them cope with these
demanding after school and weekend job. He started to          painful ideas. Histrionic patients may believe, “If I am
have negative thoughts about himself and his perform-          dramatic, people will pay attention to me and they will
ance. “I must be stupid. I can’t believe I did so badly on     accept me.” The corresponding negative belief, however,
those math tests.” “It’s humiliating to be dropped from        is “If people don’t pay attention to me, it means I’m noth-
the team. I’m such a loser.” “I don’t understand what to       ing.” Obsessive-compulsive personality disorder patients
do. This job is too hard. I can’t do anything right.”          believe, “If I control myself and others, setting up sys-
   Joe had an underlying specific vulnerability to situa-       tems of order, then I’ll be okay. But if I don’t, my world
tions in which his sense of efficacy was challenged, and        will fall apart.” Narcissistic patients hold the belief, “If
he began to attend selectively to experiences that sup-        people give me the respect and entitlements I want, it
ported his view of himself as inadequate. He began to          will show I’m superior. But if they don’t, it means I’m in-
interpret more and more situations in light of this belief     ferior.” Eating disorder patients believe, “If I control my
(his performance in other classes, his estimation of his       eating, I’ll be thin, and therefore acceptable. But if I
general intellectual and athletic abilities, his standing      don’t, my eating will go out of control, I’ll gain weight
among his peers). Feeling inadequate, he began miss-           and be unacceptable to myself and others.”
ing classes, avoiding basketball practice, doing his              When individuals’ beliefs are extreme, they display
homework superficially, skipping work, and spending a           overdeveloped behavioral strategies (compensatory or
lot of time in bed, watching television. A recognition of      coping) to protect themselves or compensate for their
these dysfunctional behaviors strengthened Joe’s nega-         perceived deficiencies, and they tend to use these
                                                  Beck Therapy Approach                                                  163
strategies in an undiscriminatory manner, even when            chronic fatigue syndrome, migraine headaches, and
they are maladaptive. They fail to develop a broad             non-cardiac chest pain, among others.
range of strategies that would be more adaptive in
many situations. Dependent patients, for example, in-
ordinately rely on others, borderline patients reject oth-                         IV. SUMMARY
ers to avert being rejected themselves, substance abuse
patients use drugs or alcohol to avoid intolerable emo-           Cognitive therapy is a form of psychotherapy that
tion, hypochondriacal patients continually check their         has been empirically supported in over 325 outcome
bodies for signs of disease or infirmity.                       studies for a variety of psychiatric disorders, psycho-
   The relationships among an individual’s develop-            logical problems, and medical conditions with psycho-
mental experiences, his or her core beliefs, assump-           logical components. It is based on the cognitive model:
tions, and compensatory strategies are illustrated in the      that individuals’ interpretations and perceptions of cur-
top half of Figure 1. The bottom half shows how these          rent situations, events, and problems influence how
underlying factors influence the individual’s interpreta-       they react emotionally, behaviorally, and physiologi-
tion of and reaction to current situations. This concep-       cally. Treatment varies according to the cognitive for-
tualizaton helps guide the therapist in modifying              mulation of patients’ disorders and therapists’ cognitive
patients’ dysfunctional thinking and behavior.                 conceptualizations of specific patients. Generally, cog-
                                                               nitive therapy is short term, structured, collaborative,
                                                               educative, and focused on working toward specific be-
                                                               havioral goals, solving current problems, alleviating
                   III. EFFICACY                               symptoms, and providing relapse prevention strategies.

   Andrew Butler and Judith Beck conducted an analy-
sis of fourteen meta-analyses of cognitive therapy out-               See Also the Following Articles
come studies in 2000. They found substantial support           Behavior Therapy: Historical Perspective and Overview I
for the efficacy of cognitive therapy in 325 studies,           Behavior Therapy: Theoretical Bases I Cognitive Appraisal
comprising 9,000 patients. Cognitive therapy was               Therapy I Cognitive Behavior Group Therapy I Cognitive
found to be somewhat superior to antidepressant med-           Behavior Therapy I Eating Disorders
ications in the treatment of adult unipolar depression.
A significant finding was that depressed patients                                 Further Reading
treated with cognitive therapy had half the relapse rate
                                                               Alford, B. A., & Beck, A. T. (1997). The integrative power of
(30%) of those who had taken medication (60%). Cog-
                                                                  cognitive therapy. New York: Guilford Press.
nitive therapy was found to be superior to supportive          Beck, A. T. (1997). The past and future of cognitive therapy.
and nondirective therapies for adolescent depression              Journal of Psychotherapy Practice and Research, 6, 1–10
and equally effective as behavior therapy for obsessive-       Beck, A. T., Freeman, A., Pretzer, J., Davis, D., Fleming, B.,
compulsive disorder. Cognitive therapy was superior to            Ottaviani, R., Beck, J., Simon, K., Padesky, C., Meyer, J., &
a number of miscellaneous psychosocial treatments for             Trexler, L. (1990). Cognitive therapy of personality disor-
sexual offenders. Cognitive therapy was also efficacious           ders. New York: Guilford Press.
                                                                                                   .,
                                                               Beck, A. T., Rush, A. J., Shaw, B. F & Emery, G. (1979). Cog-
in the treatment of bulimia nervosa.
                                                                  nitive therapy of depression. New York: Guilford Press.
   Other research studies have demonstrated the effi-           Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New
cacy of cognitive therapy for generalized anxiety disor-          York: Guilford Press.
der, panic disorder, and hypochondriasis. It has also          Clark, D. A., Beck, A. T., & Alford, B. A. (1999). Scientific
been shown to be effective for inpatient depression,              foundations of cognitive theory and therapy of depression.
posttraumatic stress disorder, substance abuse, pho-              New York: Guilford Press.
bias, social phobia, marital problems, and some person-        Clark, D. M., & Fairburn, C. G. (Eds.). (1997). Science and
                                                                  practice of cognitive behavioral therapy. New York: Oxford
ality disorders. Combined with pharmacotherapy, it is
                                                                  University Press.
effective for the symptoms of bipolar disorder and even                      .
                                                               Salkovskis, P M. (Ed.). (1996). Frontiers of cognitive therapy.
schizophrenia.                                                    New York: Guilford Press.
   Recently, cognitive therapy has been used in med-           Tarrier, N., Wells, A., & Haddock, G. (Eds.). (1998). Treating
ically related disorders, and there is substantial sup-           complex cases: The cognitive behavioral therapy approach.
port for its efficacy in the treatment of chronic pain,           London: John Wiley & Sons.
                                Behavioral Assessment
                                  David C. S. Richard                   Stephen N. Haynes
                                   Eastern Michigan University      University of Hawaii at Manoa




    I.Description of Behavioral Assessment                                 (e.g., frequency, duration, magnitude, cyclicity, or rate of
   II.Theoretical Bases                                                    an event).
  III.Goals and Objectives of Behavioral Assessment                     facets The components that contribute to an overall whole,
  IV. Features of Behavioral Assessment                                    as in facets of a construct or variable.
   V. Methods of Behavioral Assessment                                  functional analysis The identification of important, control-
  VI. Factors Affecting Inferences Made from Behavioral                    lable, causal functional relations relevant to the expres-
      Assessment Data                                                      sion of a target behavior for an individual. The term also
 VII. Clinical Case Formulation                                            is used to describe the experimental manipulation of hy-
VIII. Computers and Behavioral Assessment                                  pothesized controlling variables as a means of determin-
  IX. Summary                                                              ing functional relations.
      Further Reading                                                   functional analytic clinical case model (FACCM) A vector
                                                                           graphic representation of a clinical case formulation.
                                                                           Causal relationships between variables are expressed using
                                                                           unidirectional or bidirectional arrows. Clinical case mod-
                            GLOSSARY                                       els visually express (1) the importance of a target problem,
                                                                           (2) relationships among target problems, (3) relationships
accuracy The correctness, precision, and exactness of psy-                 between target problems and their effects, (4) the modifia-
   chological measurement.                                                 bility of antecedent or causal variables, (5) the clinical util-
antecedent event A stimulus or event that occurs prior to a                ity or importance of antecedent or causal variables, (6) the
   response or subsequent event.                                           role of unmodifiable causal variables (i.e., original causal
content validity The degree to which elements of an assess-                variables), and (7) the role of moderating variables. Path
   ment instrument are representative of, and relevant to, the             coefficient calculations suggest which causal variables, if
   targeted construct for a specific assessment purpose. Ap-                modified, would likely lead to the greatest amount of
   plied to behavioral assessment, content validity refers to              change in the client’s presentation.
   the degree to which a selected assessment method facili-             functional relation A relation between two events that may be
   tates collection of data that are representative of behavior            expressed in the form of an equation. A functional relation
   in the client’s natural environment.                                    does not imply a causal relation. Examples of a functional
context (setting) A naturally occurring environmental unit hav-            relation include the conditional probability that one event
   ing physical, behavioral, and temporal properties. The con-             may occur given another event (e.g., permitting a child
   text may affect the response of an individual to presented              to play a video game after his or her homework is com-
   stimuli, often through classical or operant conditioning.               pleted), covariation between two events (e.g., the correla-
dimension, of a behavior problem or causal variable A prop-                tion between increased heart rate and self-reported distress
   erty of an event, or series of events, that can be quantified            during an imaginal exposure trial), and the identification of



Encyclopedia of Psychotherapy                                                                           Copyright 2002, Elsevier Science (USA).
VOLUME 1                                                          165                                                       All rights reserved.
166                                                     Behavioral Assessment

   controlling variables for a behavior problem through exper-       social learning traditions, behavioral assessment em-
   imental manipulation.                                             phasizes the measurement of contemporaneous causal
idiographic assessment An assessment strategy emphasizing            variables and environmental response contingencies
   the individual or individual case. Idiographic assessment         using empirically validated assessment instruments.
   procedures often are not standardized, and observed rela-
                                                                     Thus, behavioral assessment includes a family of meth-
   tions and results are not necessarily generalizable across
                                                                     ods and instruments that measure behavioral change
   persons or groups.
level of inference (specificity) The number of elements or            through direct and indirect observation of clients’ be-
   components subsumed by the variable label. An example             havior problems and the variables that maintain those
   of a higher level construct is “depression” since the label       problems. While the variables that cause or maintain a
   subsumes multiple lower-level phenomena such as mo-               client problem often reside in an individual’s external
   toric slowness, sad affect, insomnia, eating disturbances,        environment, assessment of covert events (e.g., cogni-
   and other more specific variables.                                 tions, physiological responses) have been incorporated
nomothetic assessment An assessment strategy in which                within a behavioral assessment framework.
   judgments are based on the comparison of measures from               In pretreatment applications, data collected during
   the target person with data on the same instrument gath-          behavioral assessment must be synthesized by the clini-
   ered from other persons, such as the use of normative or
                                                                     cian and this synthesis, in the form of a behavioral clin-
   comparison groups.
phase–space relationship The expected, or realized, time-            ical case formulation, often guides treatment selection.
   course context of a variable. The phase state of a variable is    Clinical case formulations are a series of hypotheses
   its historical and projected curve at the time of measurement.    that may be evaluated in light of an ongoing clinical in-
reactive effects The degree to which the behavior of an ob-          formation collection process. As such, behavioral as-
   served individual is modified by the assessment method.            sessment is an iterative process—it is an ongoing,
response class A group of behaviors that are topographically         hypothesis-testing approach to clinical assessment. As-
   dissimilar yet produce the same functional effect.                sessment methods and resulting clinical judgments may
response contingency A conditional relationship between two          be adapted to new information that causes the clinician
   variables such that the occurrence of one variable or event is    to reevaluate initial hypotheses of client functioning
   dependent on the occurrence of the other variable or event.
                                                                     (see Fig. 1). Contemporary behavioral assessment em-
response mode The form, type, or method of behavior. Re-
   sponse modes are organizational categories or a taxonomy
                                                                     phasizes the dynamic and contingent relationship be-
   of behavior. Response modes can include motor, verbal,            tween assessment, clinical case formulation, hypothesis
   cognitive, and physiological events (or a combination of          testing, and intervention.
   these, such as emotion).
state of a variable The current level of the variable when
   measured. Unlike the phase of a variable, the state does not
   provide information on the variable’s historical course.
                                                                                II. THEORETICAL BASES
stimulus class A set of topographically dissimilar stimuli that
   evoke either the same behavior or a set of behaviors that            Behavioral assessment is an integral adjunct to be-
   have similar functions.                                           havior therapy and, like behavior therapy, evolved from
target behavior A response, or response class, that has been se-     basic behavioral research. Behavioral psychology has
   lected by the clinician for measurement and modification.          frequently been divided into two related models of
treatment utility The degree to which data from one or               learning: respondent conditioning and operant condi-
   more assessment instruments, or from a model of clinical
                                                                     tioning. Early work in respondent conditioning
   case formulation, are associated with increased treatment
                                                                     demonstrated that both humans and nonhumans
   effectiveness.
                                                                     learned new behavioral responses as a function of the
                                                                     association of extrinsic stimuli. Early in the twentieth
                                                                     century, Ivan Pavlov showed that dogs could learn new
             I. DESCRIPTION OF                                       reflexive behavior after being presented with a series of
          BEHAVIORAL ASSESSMENT                                      paired stimulus associations. Shortly thereafter, John B.
                                                                     Watson and Rosalie Rayner showed that, in humans,
   Within the broad scope of psychological assessment,               emotional responding to a previously neutral stimulus
behavioral assessment is distinguished by its emphasis               could be acquired by pairing a neutral stimulus with a
on empirically supported, multimethod, and multi-                    loud noise. Treatment methods based on respondent
informant assessment of precisely defined, observable                 conditioning principles would later be refined by Mary
behaviors. Consistent with respondent, operant, and                  Cover Jones, Joseph Wolpe, and others.
                                                  Behavioral Assessment                                                      167




FIGURE 1 A dynamic model of behavioral assessment. Adapted from Haynes and O’Brien (2000), Principles and practice of
behavioral assessment. New York: Kluwer Academic/Plenum Publishers.


   The operant, or instrumental, model of learning is          variables that maintain a target behavior (i.e., the be-
illustrated by the work of E. L. Thorndike and B. F      .     havior to be modified) in a functional analysis.
Skinner. Thorndike found that learning occurred                   For example, behavioral assessment with a Vietnam
when behavior was instrumental in, or had the effect           veteran diagnosed with posttraumatic stress disorder
of, achieving a reward (e.g., cats would learn a novel         might identify certain conditional stimuli (e.g., the
behavior if the effect of engaging in the behavior was         sound of a truck backfire, the whir of helicopter
instrumental in acquiring food). Thorndike called              blades) as having a high probability of eliciting flash-
this principle “the Law of Effect.” Skinner extended           backs and emotional responses because of their simi-
Thorndike’s work by identifying the effects of specific        larity to, or association with, aversive historical
types of consequences on behavior. According to                events. Operant responses may initially help the client
Skinner, reinforcing consequences increased the rate           cope with anxiety (e.g., drinking alcohol to induce in-
of behavior while punishing consequences decreased             toxication and facilitate avoidance). Thus, a two-fac-
the rate of behavior. Behavior that was not reinforced         tor model of the patient’s behavior incorporating both
eventually was extinguished from the animal’s reper-           respondent and operant principles would form the
toire and the rate of extinction depended on the or-           basis of a functional analysis for the patient (see
ganism’s reinforcement schedule history.                       Mowrer’s 1947 work).1
   Behavioral principles, initially studied in animal lab-
oratories, formed the foundation of behavior therapy
and have guided the development of behavioral assess-                   III. GOALS AND OBJECTIVES
ment methods. Because antecedent events and re-                        OF BEHAVIORAL ASSESSMENT
sponse contingencies shape and affect an individual’s
behavioral repertoire, a goal of behavioral assessment is        The primary objectives of behavioral assessment in-
to identify those events and contingencies that main-          clude identifying (1) target behavior problems (i.e.,
tain behavior. Antecedent events and response contin-          the problems that are to be modified) and establishing
gencies that maintain the rate of behavior are called
controlling or maintaining variables. The identification           1 Whereas Mowrer emphasized a two-factor model of condition-
of controlling variables and their relationship to the         ing, contemporary behavioral models stress the importance of family
target behavior is called a functional analysis. Thus, an      functioning, biological determinants, cognition, cultural processes,
important goal of behavioral assessment is to identify         and other factors when assessing functional relations.
168                                                     Behavioral Assessment

                         TABLE 1                                     intermediate, and ultimate intervention goals; and (4)
              Goals of Behavioral Assessment                         any adaptive or appropriate alternative behaviors to
                                                                     the target behaviors. In addition, behavioral assess-
 1. Supraordinate goal: Increase the validity of clinical            ment data form the foundation for a functional analy-
    judgments                                                        sis, suggest appropriate intervention strategies, can be
 2. Obtain informed consent from client                              used to evaluate ongoing intervention efforts, may
 3. Select an appropriate assessment method (e.g., direct            identify therapy process variables that can affect treat-
    observation, indirect observation, psychophysiological
                                                                     ment outcome, and can inform diagnostic decision
    measurement)
 4. Determine if consultation and referral are appropriate
                                                                     making. Table 1 outlines the multifaceted goals of be-
    (e.g., determine if medication consultation with                 havioral assessment.
    a psychiatrist is appropriate when working with a child             The supraordinate goal of behavioral assessment is
    diagnosed with attention deficits)                                to increase the validity of clinical judgments to facili-
 5. Development of a clinical case formulation                       tate clear formulation and treatment selection. Ulti-
    a. Identify behavior problems and their interrelations           mately, the formulation should have treatment utility.
    b. Identify causal variables and their interrelations            Treatment utility is the degree to which data from one
 6. Design of intervention programs                                  or more assessment instruments, or from a model of
    a. Identify client intervention goals and strengths
                                                                     clinical case formulation, are associated with increased
    b. Identify variables that may moderate intervention
       effects (e.g., occupational status, family support, other     treatment effectiveness.
       life stressors)                                                  The selection, evaluation, and refinement of treatment
    c. Assess client knowledge of goals, problems, and               goals and strategies can be among the most complex and
       interventions                                                 vexing tasks that clinicians face. Haynes, Leisen, and
    d. Evaluate any medical complications that could affect          Blaine in 1997 reviewed 20 studies that examined the re-
       intervention process or outcomes                              lationship between components of a functional analysis
    e. Identify potential side effects of intervention               and treatment outcome. They found that the studies
    f. Assess acceptability of intervention plan for client
                                                                     were moderately supportive of the treatment utility of a
    g. Assess time and financial constraints of therapist
       and patient
                                                                     functional analysis but that methodological limitations
 7. Intervention process evaluation                                  limited the inferences that could be drawn from the
    a. Evaluate intervention adherence, cooperation,                 studies. At the very least, it is reasonable to assume that
       and satisfaction                                              interventions are more likely to be effective if there is a
    b. Evaluate client–therapist interaction and rapport             close relationship between the causal variables identified
 8. Intervention outcome evaluation (immediate, intermedi-           in the preintervention assessment and those variables
    ate, and ultimate intervention goals)                            targeted for modification during the intervention.
 9. Diagnosis (behavioral assessment strategies can be used             Although an accurate functional analysis is a goal of
    to increase the validity of information on which diagno-
                                                                     behavioral assessment, factors other than the func-
    sis is made)
10. Predicting behavior (e.g., dangerousness and self-harm           tional analysis can influence client responsiveness to
    assessment)                                                      treatment. Examples of other factors that can affect
11. Informed consent (i.e., inform clients and other relevant        treatment outcome include the quality of treatment de-
    parties about the strategies, goals, and rationale of            livery, cooperation of persons in the client’s environ-
    assessment)                                                      ment, the client’s cognitive and physical limitations,
12. Nonclinical goals                                                cultural and ethnicity factors, the developmental level
    a. Theory development (e.g., evaluating learning models          of the client, and therapist–client rapport. Because so
       for behavior problems)                                        many factors may affect treatment outcome, isolating
  b. Assessment instrument development and evaluation
                                                                     the putative effects of a functional analysis on treat-
  c. Development and testing of causal models of behavior
      disorders                                                      ment outcome is difficult.
                                                                        Information collection can only occur in the context
   Note. Table adapted from Haynes & O’Brien (2000), Principles      of a fully informed client who understands the ration-
and practice of behavioral assessment. New York: Kluwer Academic/    ale and strategies of the assessment. The goals of as-
Plenum Publishers.
                                                                     sessment and treatment should be carefully discussed
                                                                     with the client when possible and should reflect a co-
whether the problems involve behavioral excesses or                  operative approach. In addition, the clinician should
deficits; (2) causal and moderating variables that in-               discuss with the client hypotheses of functional rela-
fluence target behavior dimensions; (3) immediate,                   tions operating in the client’s life.
                                                  Behavioral Assessment                                                169

             IV. FEATURES OF                                   sessment instruments, informants, contexts, settings, and
         BEHAVIORAL ASSESSMENT                                 response modes (e.g., behavioral, physiological, cogni-
                                                               tive). The rationales for these strategies are (1) clients
           A. Assessment Strategies                            often behave differently across situations as a function of
                                                               contingencies and contexts associated with each situa-
   Behavioral assessment emphasizes repeated meas-             tion; (2) multiple measures across time help capture the
urement, quantification, multimethod and multimodal             dynamic nature of behavior and functional relations; and
assessment, and assessment of behavior as it occurs            (3) informants differ in their source of information about
naturally. Although assessment of behavior on just one         a client and data from each informant may include
occasion may provide an estimate of its current state, it      unique sources of measurement error. Overall, these as-
does not provide information regarding changes in be-          sessment strategies help reduce the effect of measure-
havioral patterns over time, or the phase of the behav-        ment error from any single information source.
ior. For example, how a therapist interprets a Beck               The emphasis on multimodal assessment recognizes
Depression Inventory (BDI) score of 25, which sug-             that different response modes (e.g., behavioral, physio-
gests clinical levels of depression, depends significantly      logical, cognitive) may demonstrate different time
on the previous week’s BDI score and the pattern of BDI        courses, may vary in their responsiveness to hypothe-
scores over previous sessions. If a score of 25 represents     sized causal variables, and may differ in their response
a 10-point drop from the client’s last BDI results, the        to a therapeutic intervention. For example, combat vet-
clinician might infer that the depression may be less se-      erans treated with exposure techniques (e.g., imaginal
vere today than it was a week ago. However, a 10-point         exposure, systematic desensitization) for posttraumatic
change in the opposite direction would be interpreted          stress disorder often report reduced nightmares and in-
quite differently.                                             trusive thoughts; however, little or no change may
   Interrupted time series designs are sometimes used in       occur in other modes of responding. Thus, changes in
behavioral assessment to assess state–phase relation-          one mode may not necessarily be accompanied by com-
ships. These strategies emphasize repeated measurement         mensurate changes in another mode if the modes are
of behaviors, assessment of at least one causal variable       controlled or maintained by different variables.
across time, and systematic manipulation of hypothe-              The emphasis on environmental variables means that
sized causal variables. They are powerful designs for          behavioral assessment emphasizes a social-systems view
measuring both the state and the phase of a behavior and       of behavior problems—client behavior problems can
assessing cause–effect relationships between a behavior        best be understood by taking into consideration medical,
and its hypothesized maintaining variables.                    family, work, cultural, religious, and other social sys-
   The behavioral assessment paradigm also empha-              tems. For example, a case formulation of a child with ag-
sizes data quantification—the assignment of numbers             gressive behavior problems may need to take into
to variables targeted in an assessment. For example, as-       account contextual cues that evoke hitting and other
sessors may obtain measures of a client’s self-reported        aversive behaviors. However, a comprehensive case for-
level of anxiety in group social situations using a sub-       mulation might also include consideration of the quality
jective units of distress scale. Measures might also in-       of parenting practices or whether the educational setting
clude the frequency with which one marital partner             is structured in a way that positively facilitates a teacher’s
compliments another during a problem-oriented dis-             ability to manage the child’s aggressive behaviors. A suc-
cussion, the proportion of times a child’s self-injurious      cessful intervention to reduce the aggressive behaviors
behavior is followed by attention from a teacher, or           of such a child might involve family therapy and inter-
blood pressure readings obtained during exposure to            vention within the structure of the classroom in addition
laboratory stressors. Although qualitative information         to traditional behavior management strategies.
and judgments are always part of a behavioral clinical
case formulation, quantified data are very useful in
time series assessment, can help identify functional re-                    B. Behavior Problems,
lations, and facilitate the evaluation of treatment ef-
                                                                            Levels of Analysis, and
fects. Quantified data can also be presented in graphical
form to facilitate inferences regarding behavior change.
                                                                            Behavioral Dimensions
   In order to minimize error and make informed hy-               Often, the initial task of the behavioral assessor is to
potheses about client functioning, behavioral assessment       identify and specify the client’s behavior problems, most
emphasizes repeated measurement across multiple as-            often on the basis of client self-report or the report of a
170                                                 Behavioral Assessment

referral source (e.g., a teacher, counselor). To guide ini-      a child with a stuttering problem makes) and accept-
tial intervention foci, behavior problems are ordered            ability (e.g., whether the behavior is appropriate in a
in terms of importance. In many cases, consultation with         given social context, whether the behavior is compati-
the client will facilitate selection of the most important       ble with societal expectations or laws, or the client’s
target behaviors. However, when the client is not able to        own moral standards). An important task of the behav-
provide meaningful information about the relative im-            ioral assessor is to identify which of the above response
portance of behavior problems (e.g., clients with cogni-         dimensions is the most appropriate dimension to mod-
tive limitations), behaviors that are dangerous to the           ify and to design an assessment plan that facilitates ac-
client or to others are often selected as the first interven-     curate measurement of that dimension.
tion target.                                                        Finally, responses must be recorded in some way
   The level of specificity of a behavior problem refers to       using a reliable and accurate data coding system. The
the number of elements or component behaviors that               most common recording systems include paper-and-
are subsumed by the variable label. Behavior problems            pencil forms, electromechanical devices, audio and
characterized by low specificity are molar in their con-          video recording, and computerized data entry. Data col-
struction and subsume one or more behavioral facets.             lected during self-monitoring is often recorded in a
For example, the diagnostic construct major depression           journal or self-monitoring diary. Psychophysiological
is a molar level construct that includes several observ-         data are frequently recorded using a polygraph ma-
able, and more specific, behavior facets such as changes          chine. Even with highly standardized assessment meth-
in eating and sleep patterns and low rates of pleasurable        ods, reliability and accuracy of recording should not be
activities. Behavior problems with greater specificity            assumed. Reliable and accurate measurement of behav-
have fewer clinically important facets, require less infer-      ior is as much dependent on the definition and level of
ence for observation, and often are more amenable to             specificity of the variable being measured as it is on the
behavioral assessment methods and measurement.                   methods by which the behavior is recorded.
   Measurement of behavior implies measurement of
one or more dimensions of behavior. A behavioral di-
mension is a property of an event, or series of events,                         V. METHODS OF
that can be quantified. The dimension most often mod-                        BEHAVIORAL ASSESSMENT
ified in a behavioral treatment program is rate, or the
frequency of behavior per unit of time. For example, al-            A distinctive feature of the behavioral assessment
though the ultimate goal of an overweight client might           paradigm is the variety of assessment methods avail-
be to lose weight, the immediate goal may be to de-              able to the behavioral assessor. Table 2 provides a list-
crease daily high caloric snacking and increase the fre-         ing of common behavioral assessment methods. We
quency of daily exercise. Treating a child with autism           now introduce each behavioral assessment method,
often means decreasing the rate of self-injurious behav-         discuss examples of the behavioral assessment method
iors while increasing development and frequency of               drawn from the empirical literature, and review factors
self-help skills. Behavioral marital therapy might in-           that affect the validity of inferences that are derived
clude decreasing the rate of negative or sarcastic re-           from each behavioral assessment method.
marks while increasing the rate of proactive verbal
communication and problem-solving.
                                                                            A. Behavioral Observation
   Other dimensions often measured in behavioral as-
sessment include (1) the magnitude or intensity of the           1. Naturalistic Behavioral Observation
behavior (e.g., decreasing the intensity of a fear or anx-          Naturalistic behavioral observation is a behavioral
iety response); (2) the duration of the behavior (e.g.,          assessment method in which an individual is observed
decreasing perseveration on a task, increasing time              in his or her natural environment (e.g., home, school,
studying, increasing time in the presence of a feared            work), usually in a context that is most associated with
stimulus); (3) the latency of behavioral responses (e.g.,        a problem behavior. Typically, observations are made
decreasing response time to a stimulus); (4) interre-            on a predetermined schedule by one or more observers.
sponse time (e.g., the time between two instances of a           A time sampling interval is determined a priori (e.g.,
response; for example, the time between two instances            20-second periods, 5-minute periods) and the observer
of a child’s disruptive behavior in a classroom); and (5)        records the occurrences of the target behavior and/or
qualitative aspects including the physical features of           other relevant events during the interval. Multiple ob-
the behavior or its topography (e.g., the types of errors        servers are often used and percentage agreement or
                                                    Behavioral Assessment                                                   171
                                                          TABLE 2
                                              Behavioral Assessment Methods

Method                                   Types and descriptions                          Instruments and measurement devices

Behavioral observation     Naturalistic behavioral observation involves                Child Behavior Checklist Direct
                             measurement of overt behavior in the individual’s           Observation Form; Revised Edition
                             natural environment. Example: Observe a child’s             of the School Observation Coding
                             behavior in a classroom or at home.                         System; Marital Interaction Coding
                           Analogue behavioral observation involves the                  System.
                             measurement of a client’s overt behavior in a
                             contrived situation that is analogous to situations
                             the client is likely to encounter in his or her
                             environment. Example: Code marital interactions
                             during a marital therapy session.
Behavioral rating scales   Completed by individuals who are either familiar with       Child Behavior Checklist; Motivation
                             a client’s behavior or have the opportunity to              Assessment Scale.
                             directly observe a client’s behavior. Example: Have a
                             parent and teacher complete a child behavior checklist.
Self-monitoring            Systematic self-observation and recording of parameters     Self-monitoring forms are usually
                             (e.g., frequency, intensity) of targeted behaviors,         individually tailored to an individual’s
                             environmental events, cognitions, and/or mood states.       target behavior problem(s).
                             Example: Have a client diagnosed with anorexia
                             nervosa complete an eating diary after each meal.
Psychophysiological        Measurement of physiological and motoric                    Polygraphs, heart rate monitors,
  assessment                 components of behavior problems using a                     amplifiers are available through several
                             variety of measurement devices, especially                  commercial companies.
                             electromyographic, EEG, cardiovascular, and
                             electrodermal measures. Example: Record heart
                             rate, galvanic skin response, and blood pressure
                             of trauma survivor while the client listens to
                             a script recounting the traumatic event.
Self-report                Behavioral Interview: A structured or semistructured        Functional Analysis Interview Form;
                             interview that assesses dimensions of a client’s            Drug Lifestyle Screening Interview;
                             behavior, behavior–environment interactions,                Alcohol Use Inventory
                             behavioral contexts, and the functional relation
                             of the behavior(s) with other controlling variables.
                             Example: Interview inmates in a residential drug
                             treatment facility using the Drug Lifestyle Screening
                             Interview (see Walters, 1994).
                           Behavioral Questionnaire: A measurement instrument          Motivation Assessment Scale; State and
                             completed by the client, or individuals that know          Trait Food Cravings Questionnaire
                             the client well, that assesses (1) behavioral
                             dimensions and (2) functional relations of behaviors
                             with cognitions, emotional states, and other
                             controlling variables. Example: Have a client
                             complete the State and Trait Food Cravings
                             Questionnaire to identify conditions under which
                             food cravings occur and the cues that elicit cravings.



other statistics are calculated (e.g., kappa) to ensure re-        children diagnosed with attention deficit–hyperactivity
liable data recording.                                             disorder (ADHD) in their classrooms and systematically
   Naturalistic behavioral observation has been used as            varied each child’s daily dose of methylphenidate (MPH).
an assessment method to assess a wide array of behaviors.          By observing multiple, operationally specific behaviors
For example, Gulley and Northrup in 1997 observed two              over time (e.g., social behavior, disruptive behavior,
172                                                 Behavioral Assessment

efficiency at solving math problems, responses to com-            fects the validity of inferences that are made. A com-
prehension problems), they were able to show the dosage          mon interpretive strategy for observational data is to
level of MPH that was associated with the greatest               graph data and intuitively interpret the results. O’Brien
improvement across behaviors. Teacher ratings corre-             in 1995 showed, however, that individuals using intu-
sponded with the academic, behavioral, and social meas-          itive estimation methods often underestimate the mag-
ures for one participant, but not the other, suggesting that     nitude of highly correlated variables and overestimate
teacher ratings were not necessarily sensitive to changes        the magnitude of weakly correlated variables.
in behavior as a function of medication dose.
   Data collected using naturalistic behavioral observa-         2. Analogue Behavioral Observation
tion can be affected by both participant-related and ob-            Analogue behavioral observation is a behavioral as-
server-related error variance. On the participant side,          sessment method in which a clinician observes a client’s
reactivity to the assessment method can change the rate          behavior in a contrived environment (e.g., a waiting
of a participant’s behavior and make it less likely that         room, play room, clinical setting) to assess variables hy-
observed behavior reflects behavior as it naturally oc-           pothesized to influence behavior. Although analogue as-
curs in the environment. Reactivity effects are dis-             sessment is a direct measure of behavior, the target
cussed in more detail at the end of this section.                behavior is observed outside of the individual’s natural
   Observer-related error variance can affect the accu-          environment. A special section of the journal Psycholog-
racy of observations in a potentially endless number of          ical Assessment (Vol. 13, No. 1) is devoted to a discus-
ways. For example, the degree of observer training can           sion of analogue behavior observation.
affect observer reliability and accuracy. Cumbersome                There are several classes of analogue behavioral as-
recording forms or poorly operationalized behaviors              sessment. Each class includes many different instru-
can lead to unreliable coding. Raters can “drift” in their       ments for measuring behavior. A role-play is an
ratings if their understanding or application of coding          analogue behavioral assessment class in which a client
rules decays over time. Other observer-related factors           performs one or more behaviors in a contrived social
include observer attentional lapses during recording             situation. An experimental functional analysis is a
intervals, contamination of data if an observer is aware         structured observation session in which clients are
of another observer’s recordings, errors in time-sam-            observed while variables hypothesized to control or
pling parameters (e.g., frequency and duration of the            maintain a target behavior are systematically intro-
time-sampling parameters are incongruent with the                duced and withdrawn. Family and marital interaction
dimensions of the observed behavior), behavioral sam-            tasks is a class of analogue behavioral assessment in
pling errors (e.g., an important behavior is not in-             which members of a familial unit interact with one
cluded in the behavioral coding system), and observer            another on a task specified by the assessor that is rele-
knowledge of patient status. Frequent accuracy checks            vant to the family or couple. Behavioral avoidance
of observer ratings should be made by an independent             tests are often used to assess a person’s response to a
auditor to ensure that observer agreement indices do             feared stimulus by measuring proximity to the stimu-
not fall below an acceptable level (e.g., .80). If the ac-       lus (e.g., how close, in feet, a person with a snake
curacy of an observer’s ratings is below the criterion,          phobia can come to a snake in a glass cage) or other
retraining should be initiated.                                  approach behavior.
   The validity of inferences drawn from naturalistic               Other analogue behavioral observation techniques
observation also depends on the choice of observation            include enactment analogues, in which the individual is
setting. As a general rule, observation should occur in          observed performing a newly acquired skill; contrived
situations where the problem behavior is most likely             situation tests, in which a novel situation is presented
to occur. Because the dimensions of behavior often               to an individual to determine whether the individual
vary across situations and contexts, selecting the most          can apply newly learned skills; think-aloud procedures,
relevant naturalistic setting for observation is an im-          in which a person reports his or her thoughts during
portant decision.                                                performance of a behavior; and response generation
   How the data are aggregated and displayed can have            tasks, in which an individual engages in, or generates,
a significant bearing on the validity of inferences as            one or more response options to a stimulus event. Vari-
well. Naturalistic behavioral observation data may pro-          ants of analogue behavioral observation have been used
vide useful information when data are aggregated                 to assess a wide array of behavioral problems and
across many minutes but not in shorter intervals, and            phenomena. Hundreds of studies have employed the
vice versa. In addition, how the data are interpreted af-        technique to assess marital interactions, child behavior
                                                  Behavioral Assessment                                             173
problems, adult social functioning, and countless other        and behaviors (e.g., dysphoric affect, withdrawal) were
behavioral disorders.                                          observed too infrequently to be reliably coded in brief
   The utility of the analogue observation in helping          laboratory interactions.
the clinician generate hypotheses about functional rela-          Analogue behavioral assessment methods and their
tions depends on the degree to which the analogue              respective coding systems have generally not been sub-
context includes the elements that affect the behavior         jected to the type of psychometric rigor common for
problem in the natural environment. For example,               other psychometric instruments. For example, reports
McGlynn and Rose in 1998 observed that anxious pa-             of analogue assessment methods often do not include
tients usually fear stimulus classes, rather than a single     information about (1) the goals of the analogue assess-
stimulus, and that one analogue session would be un-           ment, (2) the specific behaviors, functional relations,
likely to include the myriad of feared stimuli present in      constructs, and facets to be measured, (3) the response
the client’s natural environment. Analogue behavioral          modes and dimensions to be measured, (4) the meth-
observation is most likely to be a cost-effective alterna-     ods of data collection, (5) how the specific scenarios,
tive to naturalistic behavioral observation when the tar-      situations, and instructions might affect client behav-
geted behavior(s) occurs with high frequency in the            ior, or (6) a discussion about how dimensions of indi-
analogue situation and is not reliably or accurately           vidual differences (e.g., sex, religion, age, ethnicity,
measured using other less costly assessment methods            sexual orientation) might influence responses. One of
(e.g., questionnaires, rating scales).                         the major difficulties in evaluating the usefulness of
   Analogue observation sessions are more likely to pro-       analogue assessment, especially in the assessment of
vide important information regarding functional rela-          child behavior problems, is the lack of standardization
tions than behavioral rates. For example, couples may          demonstrated by most available measures.
exhibit a higher frequency of negative comments toward            Closely related to standardization is the issue of reli-
one another during an initial assessment interview than        ability, or consistency of measurement. The reliability
they would at home where they could more easily avoid          of analogue behavioral observation coding systems is
their spouse or partner. Alternatively, behaviors that         generally not well studied. For example, one researcher
occur only in private contexts may not occur at all in an      concluded that only 20% of published marital commu-
analogue situation (e.g., battering, verbal threats). Re-      nication studies included reliability information for the
searchers have long noted that partial-interval recording      constructs that were studied. Another researcher con-
in analogue settings underestimates high rate respond-         cluded that no test-retest reliability data are available
ing, does not produce valid estimates of behaviors of          for parent-directed-play coding systems or free-play be-
short durations, and can misrepresent temporal relation-       havior coding systems.
ships between behaviors and events.                               Additionally, the external validity of most analogue
   The novelty of the assessment environment may make          assessment measures has not been well investigated.
it more likely that irrelevant behaviors, rather than the      External validity, in the analogue context, is the degree
target behavior, are observed. For example, a child who        to which behavior observed in the analogue setting is
is defiant toward his parents may be stimulated by unfa-        representative of the client’s behavior in his or her nat-
miliar objects and toys in an observation room and may         ural environment. Norton and Hope in 2001 concluded
not interact with a parent as a result. Nonetheless, role-     that the evidence concerning the external validity of
play activities may still permit observation of related        role-play methods is “equivocal” and data on the exter-
variables and their dimensions (e.g., tone of voice, eye       nal validity of other analogue assessment classes are ei-
contact, frequency of reflective statements made by each        ther insufficient or absent.
partner).
   All forms of analogue behavioral assessment require                    B. Behavioral Rating Scales
a coding or rating system in which the assessor quanti-
                                                                          and Behavioral Checklists
fies a dimension of behavior. For example, Heyman and
Vivian in 1993 developed the Rapid Marital Interaction           A behavioral rating scale is an assessment instrument
Coding System (RMICS) to facilitate analogue observa-          completed by a clinician or a third party (e.g., signifi-
tion of marital communication styles. In 2001 Heyman           cant other, teacher, parent, peer) that includes items
and colleagues found that observation periods as brief         that assess one or more targeted client behaviors. A
as 15 minutes were sufficient to obtain stable estimates        behavioral checklist is similar to a behavioral rating
of most RMICS codes in maritally distressed couples.           scale but often includes fewer items and may include di-
However, in happily married couples, some variables            chotomously scored response options. Many behavior
174                                               Behavioral Assessment

rating scales and behavioral checklists have been stan-           In addition to being indirect measures of behavior, be-
dardized using a normative sample of individuals and           havior rating scales and behavioral checklists rarely pro-
aggregate raw data into standardized scale scores or           vide information pertaining to the functional relations of
global scores.                                                 variables. Most behavior rating scales and behavioral
   Behavioral rating scales are frequently divided into        checklists include items that measure topographical be-
two classifications: narrow band behavior rating scales         havioral dimensions rather than functional relations. To
and broad band behavior rating scales. Narrow band             some degree, the contextual variability of behavior can
behavior rating scales include items that sample from a        be addressed by having multiple informants complete
small number of domains and are not intended to be             the instrument provided each informant observes the
global measures of an individual’s behavior. Broad             client in different contexts (e.g., having a parent and a
band behavior rating scales usually include more               teacher complete the same rating scale). A thorough
items, sample from a wider spectrum of behaviors, and          functional assessment, however, requires greater atten-
are often used to screen for more than one disorder or         tion be paid to other variables that may be maintaining
behavioral syndrome.                                           the behavior (e.g., the type of reinforcement received for
   For example, behavioral checklists and behavioral           an oppositional behavior; whether the problem behavior
rating scales are the most popular methods of gathering        results in avoidance of an aversive event or situation).
information in assessing ADHD. Narrow band meas-
ures include the 55-item Social Skills Rating System,
which divides item content into three narrow domains:
                                                                   C. Psychophysiological Assessment
problem behaviors, social skills, and academic compe-             Psychophysiological assessment involves recording
tence. Another narrow band instrument is the Disrup-           and quantifying various physiological responses in
tive Behavior Rating Scale (DRS). The DRS includes             controlled conditions using electromechanical equip-
item content covering oppositional defiant disorder,            ment (e.g., electromyography, electroencephalography,
ADHD, and conduct disorder. Broad band behavioral              electrodermal activity, respiratory activity, electrocar-
rating scales include the Child Behavior Checklist             diography). Which response or response system is
(CBCL) and the Conners Parent and Teacher Rating               measured depends on the purpose of the assessment.
Scales. Both the CBCL and the Conners Scales provide           Psychophysiological measurement has been used to as-
several scale scores and include versions for parents,         sess autonomic balance (e.g., heart rate, diastolic blood
teachers, and youths to complete. The popularity of            pressure, salivation), habituation to environmental
these behavioral assessment methods can be attributed          stimuli, reactivity to traumatic imagery, orientation re-
to their cost-efficiency, ability to quantify the opinions      sponse, and other physiological systems.
of important persons in a client’s life, and their ease of        Frequently, the behavioral assessor is not so much in-
administration. In addition, the most widely used in-          terested in the behavior measured by the equipment as
struments (e.g., the CBCL) rest on an extensive foun-          what may be inferred from the behavior. For example, a
dation of empirical literature that testifies to their          large literature exists with regard to the psychophysio-
reliability and validity.                                      logical measurement of responses to anxiety-eliciting
   Although behavioral rating scales and behavioral            stimuli. Keane and co-workers in 1998 showed that
questionnaires are popular, it should be emphasized            male military veterans with posttraumatic stress disorder
that they are indirect measures of behavior. As indirect       (PTSD) exhibited greater changes in psychophysiologi-
measures, data collected using behavioral rating scales        cal responding (i.e., increased heart rate, skin conduc-
and behavioral checklists reflect a rater’s retrospective       tance, systolic and diastolic blood pressure) when
impression of a client’s behavior rather than an objec-        presented a series of trauma-related cues than did veter-
tive recording of the rate at which behavior occurs, as        ans without PTSD. Other studies have found increased
with naturalistic behavioral observation methods. Con-         physiological responsivity in females with PTSD and in-
sequently, all behavioral rating scales and behavioral         creased heart rate responses to startling tones in individ-
checklists are subject to rater bias regardless of the         uals with PTSD.
rigor with which the instrument is designed. Although             Selection of the eliciting stimulus, or stimuli, and the
indirect observation of behavior can be useful in behav-       response modes to monitor during a psychophysiologi-
ioral assessment, its limitations need to be understood        cal assessment are important considerations, especially
by the behavioral assessor.                                    when investigating responses to trauma-related cues.
                                                   Behavioral Assessment                                             175
For example, research has consistently shown that indi-         wrist terminals, ambulatory measurement devices, and
viduals are more physiologically reactive to scripts de-        handheld computers to signal, and sometimes record,
tailing their own personal experiences than to                  client behavior.
standardized scripts detailing either neutral scenes or            Most self-monitoring recording instruments are de-
traumatic situations. Synchronous responding to stimuli         signed to maximize the chance of observing a func-
across physiological modes has not, however, been gen-          tional relation between a behavior and an extrïnsic
erally observed. For example, Blanchard, Hickling, Tay-         variable. A common self-monitoring record is an A-B-C
lor, Loos, and Gerardi in 1994 found that heart rate and        log. An A-B-C log is a serial record of the antecedent
electrodermal activity, but not systolic or diastolic blood     events (A) that occur prior to the behavior (B) and the
pressure, were responsive to audiotaped scripts describ-        consequences (C) or events that follow the behavior. A-
ing a motor vehicle accident the participant survived.          B-C logs are useful in identifying environmental events
   All of these studies demonstrate how psychophysio-           that are functionally related with a problem behavior.
logical assessment can be used to identify behavioral           Variants of the A-B-C log are the basis of most self-
differences in individuals, provide criterion-related va-       monitoring recording forms. For example, daily food
lidity for psychiatric diagnoses, and can be used as a          records have been used by researchers studying clients
clinical marker of client change since clinical improve-        diagnosed with bulimia nervosa. Daily food records
ment has been associated with changes in physiological          typically provide space for the client to record the time
indices. However, psychophysiological assessment is             of a meal, the food and liquid that was consumed,
often cumbersome, expensive, and, depending on the              where the food was eaten, the type of eating event (e.g.,
client and his or her problems, may not provide infor-          meal, snack, binge, purge), and the circumstances sur-
mation that sheds light on the functional relations of          rounding the food intake. Some researchers have used a
variables operating in a client’s life. In addition, psy-       daily obsessional thought record to assess obsessions,
chophysiological information does not inherently pos-           mood, and other cognitive variables. Other recording
sess greater validity or is more objective than other           formats include paper-and-pencil diaries and comput-
behavioral assessment methods. Data from a psy-                 erized diaries.
chophysiological assessment require interpretation in              The accuracy of self-monitoring data can be affected
the context of convergent evidence from other assess-           by several factors. For example, one difficulty in having
ment methods (e.g., a behavioral interview, analogue            HIV-positive males self-monitor sexual behavior is that
behavioral observation) in order for the information to         the activity of self-monitoring may affect rates of sexual
be clinically meaningful.                                       behavior (i.e., reactivity to the assessment method). In
                                                                addition, clients who are unlikely to comply with self-
                                                                monitoring instructional sets should be assessed by
                D. Self-Monitoring                              other means. Eating disorders researchers have pointed
   Sometimes neither naturalistic nor analogue behav-           out that clients with anorexia pose significant chal-
ioral observation methods are feasible. For example, a          lenges for a self-monitoring assessment methodology.
behavior may occur only in private (e.g., vomiting in a         Clients with anorexia may distort their reports of
client diagnosed with bulimia nervosa), may not be di-          caloric intake in order to mislead therapists and avoid
rectly observable (e.g., negative self-statements), may         negative consequences from family and friends. Thus,
occur in contexts that cannot be easily observed in the         the validity of self-monitoring data may be affected by
natural environment (e.g., problematic interactions             the type of eating disorder and the context of the mon-
with a work superior), or may not be easily replicable in       itoring. Clients who restrict their intake, and are keep-
an analogue assessment context (e.g., group social gath-        ing food diaries for themselves, are likely to be accurate
erings). In these situations, clients may be asked to self-     in their recording. However, if the recording is in a
monitor their own behavior. Self-monitoring refers to           treatment context, accurate recordings are less likely to
any assessment method in which clients record observa-          occur because of the constellation of influences that
tions of their own behavior to a recording form. While          could affect the client’s report. Other variables that are
most self-monitoring studies have reported methodolo-           known to affect the accuracy of self-monitoring data in-
gies in which the client records data on a predetermined        clude the number of behaviors to be monitored, social
schedule (e.g., hourly, daily, when an event occurs), re-       desirability, demand characteristics, the length of the
cent research has explored the use of electronic pagers,        recording period, the client’s awareness of accuracy
176                                              Behavioral Assessment

checks, availability heuristics, the client’s emotional       ple, Albert Farrell has developed a computer program
state when making a recording, and degree to which            that helps both clinicians and clients assess client be-
the client was trained in self-monitoring.                    havior problems and monitor treatment progress. Far-
   The wisdom of using self-monitoring techniques             rell’s program has become a seamless part of the
with children has also been questioned. Shapiro and           assessment procedures of a university clinic.
Cole in 1999 concluded that children can be reliable
monitors of their own behavior but that the technique         2. Behavioral Questionnaires
frequently leads to reactive effects that can change the         A behavioral questionnaire is a series of questions,
rate of behavior. Peterson and Tremblay in 1999 con-          often in Likert-type format, that include item content
cluded that self-monitoring in children is likely to be       designed to assess the functional relations of extrinsic
inaccurate if the behavior is contrary to medical advice,     variables with a target behavior. In contrast to traditional
when a behavior is supposed to occur but the child de-        clinical questionnaires, behavioral questionnaires usu-
liberately fails to perform it, when the behavior is so-      ally include questions that assess antecedent events, the
cially inappropriate or embarrassing, when the child is       effects of the behavior problem, and acquire data on one
not motivated to self-monitor behavior, or when the           or more behavioral dimensions. For example, Cepeda-
child may have difficulty monitoring the behavior (e.g.,       Bineto, Gleaves, Williams, and Erath in 2000 designed a
thumbsucking).                                                food cravings questionnaire with items that assess cues
   Several strategies may enhance both the accuracy of        that trigger food cravings, positive reinforcement that
collected data and the probability of client compliance.      comes from eating, relief from negative states as a result
For example, researchers recommend scheduling accu-           of eating, physiological states associated with hunger,
racy checks, selecting target behaviors that are not dif-     and emotions surrounding food cravings and eating.
ficult to code and record (e.g., self-monitored motoric
responses as opposed to verbal responses), training           3. Issues in the Use of Self-Report Instruments
participants in self-monitoring, contracting with indi-          Behavioral assessors have historically been somewhat
viduals, providing reinforcement contingent on accu-          skeptical of the inferences made from self-report data.
rate recording, providing a recording device that is          Objections include the role that client biases, memory
unobtrusive, limiting the number of behaviors to be           errors, and other factors might play in degrading the ac-
monitored, and selecting behaviors that have a positive       curacy of self-reports. However, some behavioral prob-
rather than negative emotional valence.                       lems are difficult to observe directly and the client’s
                                                              self-report may be the only source of information con-
                                                              cerning the dimensions of the target behavior. For exam-
          E. Self-Report Instruments                          ple, Sobell, Toneatto, and Sobell in 1994 concluded that
1. Behavioral Interviews                                      self-reports are a valuable, cost-efficient, and reasonable
   A behavioral interview is a set of structured or semi-     source of information when assessing patients with sub-
structured queries designed to elicit responses re-           stance abuse problems. However, they issued the caveat
garding (1) one or more overt target behaviors, (2)           that inaccurate self-reports are most likely to occur when
behavior–environment interactions, (3) the most rele-         (1) individuals may violate social conventions or the law
vant behavioral dimensions, and (4) relations of the be-      by admitting to engaging in a behavior or (2) individuals
havior(s) with hypothesized maintaining variables.            are unable to provide accurate self-reports (e.g., a de-
Behavioral interviews differ from traditional clinical        mented patient, a very young child).
interviews in that they are structured, focus on overt           Although behavioral questionnaires may be inexpen-
behavior and behavior–environment interactions, are           sive to administer, have face validity for patients, and
sensitive to situational sources of behavioral variance,      are easily scored, behavior therapists should be cautious
focus on current rather than historical behaviors and         when making inferences from instruments that are not
determinants, and define behavior at a molecular rather        developed from a behavioral framework. Traditional
than molar level.                                             clinical questionnaires often yield global or aggregate
   Behavioral interviews are sometimes cumbersome             scores that are insensitive to the conditional nature of
and time consuming to administer. However, the recent         behavior, the functional relation of behavior to an-
development of behaviorally oriented computerized as-         tecedent events and consequences, and the variability of
sessment applications has made efficient collection of         behavior across situations and contexts. In addition,
behaviorally relevant data less problematic. For exam-        variables are often defined at a molar level that is not
                                                  Behavioral Assessment                                                177
sensitive to variability of component behavioral facets.       the methods and instruments chosen for conducting the
Many individuals exhibit discordance across response           assessment capture all important aspects of client func-
modes (i.e., behavioral, physiological, cognitive) while       tioning. For example, in assessing a client complaining
most self-report questionnaires produce scale or global        of depression, the inferences derived from the assess-
scores that imply uniform responding.                          ment would be limited to the degree that the assessor
   Inferences drawn from questionnaire data are also at-       failed to assess the component facets of depression and
tenuated by the fact that self-report and observer rat-        the various modes of responding. A strategy that focused
ings often only modestly agree. For example, some              solely on identifying cognitions surrounding depressive
researchers have reported significant mean differences          symptoms might not identify important behavioral pat-
between self- and peer-reported interpersonal prob-            terns (e.g., lack of activity) that contribute to the client’s
lems. In one study reported in 1999, Handwerk,                 low mood. Thus, assessment strategies that incorporate
Larzelere, Soper, and Friman had parents of 238 trou-          multiple methods of information gathering across multi-
bled children complete the CBCL and the children               ple modes of responding are likely to minimize error
complete the Youth Self-Report (YSR), the self-report          variance associated with any one assessment method.
version of the CBCL. They found that parental ratings
of the frequency and intensity of their child’s problem
behaviors were over a standard deviation higher than
                                                                                    B. Reactivity
the self-reports made by the children. The discrepan-             Reactivity refers to changes in behavior that occur
cies were apparent across all scales, and in the same di-      in a person who is being observed as a function of the
rection (i.e., parents > children) regardless of age, sex,     assessment process. Reactivity effects can occur in all
site, and parent informant. These results suggest a lack       behavioral assessment methods and can lead to behav-
of agreement of parent and child’s appraisals of the           ioral increases or decreases depending on the behavior
child’s behavior. Another implication is that the esti-        that is being observed. Reactivity effects are often as-
mated severity of a child’s behavior will depend on            sociated with the duration of observation, the amount
whether a clinician places more weight on a child’s self-      of change in the environment associated with the ob-
report or a parent’s rating of the child’s behavior. The       servation, the identity of the observers, the amount of
assumption that responses to a questionnaire or behav-         instructions provided subjects, the goals of assess-
ioral interview accurately reflect dimensions of client         ment, and the methods of data reporting. Korotitsch
behavior is generally not warranted. Inferences based          and Nelson-Gray in 1999 suggested that variables af-
on questionnaire and interview results should be cross-        fecting self-monitoring reactivity include the valence
checked against data collected via other methods.              of the target behavior (desirable behaviors tend to in-
                                                               crease in frequency), motivation for change, the to-
                                                               pography of the target, the schedule of recording,
        VI. FACTORS AFFECTING                                  concurrent response requirements, the timing of
       INFERENCES MADE FROM                                    recording, goal-setting feedback and reinforcement,
    BEHAVIORAL ASSESSMENT DATA                                 and the nature of the recording device. Reactivity may
                                                               be mitigated or eliminated by allowing participants to
  All behavioral assessment methods include vari-              habituate to the changes introduced to their environ-
ance that is attributable to the behavior being meas-          ment because of the assessment procedure. For exam-
ured and variance that is due to measurement error.            ple, if a video recorder is introduced to a classroom,
The validity of clinical inferences can be affected by         allowing the camera to be present for a few days before
the content validity of an instrument, reactivity of in-       beginning measurements may allow children to habit-
dividuals to the assessment process, and the degree of         uate to its presence.
accuracy in measurement.                                          Emerging technological innovations can also mini-
                                                               mize reactivity effects in some situations. For example,
                                                               Boyce and Geller in 2001 reported a study in which
               A. Content Validity
                                                               the experimenters observed automobile driving behav-
  Content validity refers to the degree to which ele-          iors by utilizing several hidden cameras strategically
ments of an assessment instrument are relevant to and          placed in a moving automobile. The cameras were the
representative of the targeted construct. With regard to       size of a pinhead and recorded what the driver saw on
behavioral assessment, content validity refers to whether      the road during a 45-minute drive, the driver’s face,
178                                               Behavioral Assessment

the location of the driver’s hands, and road markings          being in a public place). However, a functional analysis
on the highway. The four video channels were fun-              may make the client aware of a relationship between the
neled to a quad-multiplexer that integrated the camera         behavior and the context and make it more likely that
views and time stamped the videotape record. The               the client is able to cope with previously anxiety-elicit-
video images were later coded in 15-second intervals           ing situations. As a result, the client may experience a
for safe driving techniques (e.g., correct turn signal         decrease in frequency of panic attacks.
use, maintaining a safe following distance from an-
other vehicle). The results showed that older partici-
pants engaged in less risky driving behaviors than                 VII. CLINICAL CASE FORMULATION
younger participants. In addition, male drivers did not
take more risks than female drivers, leading the au-              Ultimately, behavioral assessment must inform treat-
thors to suggest that previous research suggesting             ment planning and increase the probability that maxi-
greater risk-taking behavior by males may be an arti-          mally efficacious treatments are implemented. The
fact of the self-report methods that were used.                importance of developing a clinical case formulation
                                                               based on assessment results has been recognized by
                                                               workers endorsing diverse models of psychopathology.
                    C. Accuracy                                However, integration of assessment tools from diverse,
   Although many definitions of accuracy have been              and sometimes incompatible, theoretical models has
proposed in the behavioral literature, accuracy refers to      not been successful.
the extent to which data collected during a behavioral            Increasingly, clinical case formulation is being viewed
assessment approximates the true state of nature. In be-       by behavior therapists as a crucial contribution to suc-
havioral assessment, accuracy is relevant to both the          cessful treatment outcome. Recent volumes on clinical
recording (i.e., data coding) and the reporting (i.e., in-     case formulation highlight the prominent role case
terviewee responses) of behavior.                              formulation plays in treatment planning. However, ap-
   Accuracy may be attenuated in several ways. Re-             preciation for the importance of clinical case formulation
searchers have long noted that accuracy of self-moni-          in the behavioral paradigm is a relatively recent phenom-
toring data can be affected by the response mode that is       enon. Behavioral models of clinical case formulation have
monitored (i.e., cognitive, motor, or physiological be-        focused on the identification of antecedent conditions
havior). Low-frequency, overt motor behaviors appear           and behavioral effects that maintain the target problem.
to be more accurately recorded than high-frequency,            Clinical case formulations have spanned a wide array of
verbal behaviors for most individuals.                         disorders and behaviors including transient tic disorder,
   Accuracy can also be affected by recorder bias.             delusional speech in schizophrenia, trichotillomania, ob-
Recorder bias may result from a potentially endless            sessive–compulsive disorder, developmental disabilities,
number of factors: inattention, carelessness, poor train-      chronic cough, and borderline personality disorder.
ing, errors in selection of intervals during which behav-         However, the necessity of conducting a clinical case
ior is recorded, technical difficulties, and so forth.          formulation, while intuitively appealing, remains a
When multiple raters observe behavior, calculating the         subject of some debate. Studies confirming the utility
degree to which any one rater agrees with the other            of an a priori case formulation are difficult to design for
raters can help identify raters who may be systemati-          several reasons because numerous intervening vari-
cally biasing their observations and, hence, their data.       ables that are extraneous to the case formulation can
   Accuracy of reporting can fluctuate over time as a           affect a client’s behavior (e.g., client–therapist rapport,
function of a variety of respondent variables. For exam-       quality of treatment delivery, duration of the client’s
ple, Carr, Langdon, and Yarbrough in 1999 concluded            presenting problems, frequency and strength of the
that the accuracy of clients self-report is subject to (1)     client’s responses, response class parameters of the
biased or inaccurate recall of behavioral occurrences          client’s behavioral repertoire). Nonetheless, some au-
and (2) the changing functions of behavior. In addition,       thors have suggested that treatment outcome is more
modifying a client’s recognition and understanding of a        related to the accuracy of the clinical case formulation
problem behavior may affect both rates of responding           than to intervention strategies. For example, Persons,
and the client’s estimates of behavioral rates. For exam-      Curtis, and Silberschatz in 1991 proposed the formula-
ple, a client may not initially be aware of the environ-       tion hypothesis, which suggested that successful treat-
mental cues that reliably precede a panic attack (e.g.,        ment outcomes depends on the accuracy of the initial
                                                   Behavioral Assessment                                                        179
case formulation, thereby elevating the role of clinical           physiological) and contexts, considers historical
case formulation to a level on a par with, and even su-            and developmental information, and gathers data
perior to, treatment delivery. Objections to the formu-            from standardized measures, behavioral observa-
lation hypothesis include the observations that (1)                tion, and psychophysiological measures.
treatment outcome is affected by a wide variety of fac-         3. Generation of alternatives: The clinician considers
tors extrinsic to the therapeutic context, and (2) clients         different treatment options and creates a list of pos-
sometimes improve in the absence of a formal clinical              sible target variables, solutions, and interventions.
case formulation.                                               4. Decision making: The clinician evaluates the clinical
                                                                   utility of each treatment and selects the one that is
         A. The Cognitive-Behavioral                               likely to be most effective for the client.
                                                                5. Solution implementation and verification: The clini-
           Case Formulation Model
                                                                   cian works with the client using the selected treat-
   Jacqueline Persons and her colleagues have devel-               ment option and assesses outcome.
oped a cognitive-behavioral case formulation model
(CB) that focuses on the identification of overt behav-            A visual summary of the case formulation is pro-
iors and the underlying cognitive mechanisms hypoth-            vided by means of a clinical pathogenesis map. The
esized to control the behaviors. The therapist works            map is a flow diagram summarizing the relationship
with the client to create a behavior problems list, a list      between stressful events, historical factors, contempo-
of specific beliefs about himself or herself that may af-        raneous events, and behavior problems.
fect the client’s behavior problems, and a list of external
events and situations that activate core beliefs. From                         C. Functional Analytic
these data, a set of working hypotheses are developed
                                                                               Clinical Case Modeling
regarding the functional relations of problem behaviors
and maintaining variables. Causal mechanisms in CB                 Another case formulation model has been developed
are often presumed to be underlying cognitions and are          by Stephen Haynes and his colleagues. A functional
assessed using a multiple-choice questionnaire.                 analytic clinical case model (FACCM) is a means of
   Persons and her associates have found that clinicians        schematically representing a functional analysis2 using
trained in the CB show moderate agreement in their              vector graphic diagrams, as discussed by Haynes, Leisen,
lists of clients’ overt problems. Doctoral-level training,      and Blaine in 1997. FACCM variables include original
clinical formulation training, experience in cognitive-         causal variables, causal variables, moderating variables,
behavior therapy, and greater psychotherapy experi-             client behavior problems, and effects of client problems.
ence have been associated with better agreement in              Original causal variables are variables that affect client
problem identification but not in identifying schemas            behavior, either directly or through their effects on other
that may be influencing the client’s behavior.                   causal variables, and are not modifiable (e.g., events that
                                                                happened in the past, medical conditions). Causal vari-
                                                                ables are variables that affect the client’s problems and are
      B. A Problem-Solving Approach
                                                                presumed to be modifiable. Client problems are behav-
        to Clinical Case Formulation
                                                                iors or cognitions exhibited by the client that are evoked
   Whereas the model described by Persons and her               or maintained by causal variables. Finally, the effects of
colleagues emphasizes the identification of core                client problems are events or processes that follow, and
schemas that underlie behavioral problems, Arthur and           may be consequences of, client problems. In addition to
Christine Nezu have conceptualized assessment and               identifying the above variables, FACCMs communicate
therapy as a problem-solving process composed of the            the hypothesized strength of each variable in the model,
following components:

1. Problem orientation: The clinician conceptualizes               2 The definition of the term “functional analysis” varies within be-

   the client’s problem as multiply determined by psy-          havioral psychology and across disciplines that use behavioral princi-
                                                                ples. In applied behavior analysis, the term refers to the systematic
   chological, biological, and social influences.
                                                                manipulation of variables to estimate functional relations. We use
2. Problem definition and formulation: The clinician as-         Haynes and O’Brien’s more broad use of the term in 1990 to refer to the
   sesses the behavioral problem across multiple re-            identification of “important, controllable, causal and noncausal func-
   sponse modes (e.g., behavioral, cognitive, affective,        tional relations applicable to specified behaviors in the individual.”
180                                                 Behavioral Assessment




       }
                                   }
                                   }
                                   }
              FIGURE 2 A functional analytic clinical case model (FACCM) of a Vietnam war veteran’s drink-
              ing behavior and hypervigilance. Note. Using the example of the war veteran provided in the arti-
              cle, an FACCM can show both respondent and operant conditioning at work. An original causal
              variable, the combat experience, is paired with a variety of innocuous stimuli (smells, sounds,
              etc.) that will later remind the veteran of his combat experiences through respondent condition-
              ing and generalization. The trauma of the combat experience leads to intrusive thoughts and rec-
              ollections long after the veteran returns from the combat theater. Both environmental cues and
              the intrusive thoughts and recollections have the potential to elicit sympathetic nervous system
              activation (e.g., increased heart rate, respiration). Sympathetic nervous system activation can also
              reciprocally elicit intrusive thoughts and recollections (e.g., an increase in heart rate through ex-
              ercise can trigger a combat memory). The main client behavior problems thus involve alcohol
              consumption, which has the effect of temporary anxiety reduction and is maintained through
              negative reinforcement, and hypervigilance of environmental stimuli (i.e., conditioned cues in
              the environment). Sustained hypervigilance has the effect of creating a persistent sense of fatigue
              and weariness. In tandem with marital conflict caused by excessive alcohol consumption, the fa-
              tigue resulting from the client’s hypervigilance contributes to another effect, dysphoria.




the modifiability of causal variables, the strength and             example of an FACCM for a Vietnam war veteran ad-
causal direction of relationships between variables, and           dressing client behavior problems of excessive alcohol
the importance of each behavior problem. A computer                consumption and hypervigilance.
program developed by Haynes, Richard, and O’Brien in
2000 conducts a path analysis that takes into account all
                                                                                       D. Commentary
variable relationships in an FACCM and rank orders the
effect of each causal variable on the model.                          The three models described by Persons, Nezu and
   FACCMs are usually specific to a context and are not             Nezu, and Haynes provide frameworks by which clini-
assumed to be equally valid for individuals with topo-             cians can assess and understand functional relations in
graphically similar target behaviors. FACCMs are dy-               a clinical case. The models provide a systematic, gener-
namic in that they are expected to change as more                  alized way of thinking about functional relations rather
assessment information becomes available and the vari-             than suggesting causal mechanisms for a specific be-
ables affecting a target behavior change. Figure 2 is an           havior or any of its dimensions. In this way, clinical
                                                    Behavioral Assessment                                                        181
case formulation models can be thought of as templates              Several clinically applicable handheld software pro-
that guide conceptualization of functional relations             grams have been described in the literature in recent
across disorders.                                                years. Newman, Kenardy, Herman, and Barr Taylor in
   An interesting question for future research involves          1996 used a Casio PB-1000 handheld computer to
the degree to which the various clinical case formula-           prompt patients with panic four times per day to report
tion models lead clinicians to hypothesize different             anxiety levels and occurrence of panic attacks. During
functional relations in the same client. In addition, re-        the client’s office visit, data were uploaded to a desktop
searchers have yet to determine conclusively whether             computer, stored in a database, and then analyzed. Re-
clinical case formulation models enhance treatment               ports were generated that summarized client responses
outcome and which models, if any, are more likely to             to the computer. Others have recently reported using
produce incremental treatment gains.                             handheld devices to record frequency of smoking be-
                                                                 havior, measure reaction time during a prolonged, sim-
                                                                 ulated submarine crisis, measure stress reactions in the
           VIII. COMPUTERS AND                                   natural environment, and assess obsessive–compulsive,
         BEHAVIORAL ASSESSMENT                                   fibromyalgia, and dementia symptoms.
                                                                    The extent to which handheld devices will be success-
   In the future, behavioral assessment will be increas-         fully incorporated into the clinical practice depends on
ingly augmented by the use of computer technology.               cost-effectiveness, technological, and psychometric is-
Already, researchers have developed computer pro-                sues. With regard to cost-effectiveness, handheld devices
grams that help the behavioral assessor efficiently col-          may be prohibitively expensive for clinicians to use with
lect, store, and analyze data. Programs are now                  clients given that the devices are at higher risk for being
available that ease data collection and analysis across          lost, not returned, or damaged. In addition, software that
all the major methods of behavioral assessment. For              is robust enough to be generalized to a wide array of be-
example, software for event recording has replaced ear-          havior problems is not currently available for handheld
lier electromechanical devices and paper-pencil record-          devices.3 Even if the software was readily available, effi-
ing formats. Tapp, Wehby, and Ellis in 1995 developed            cient methods for conducting data analyses and incorpo-
the Multiple Option Observation System for Experi-               rating results into treatment planning have yet to be
mental Studies (or MOOSES). The software eases                   developed. Additionally, the technological learning
event-based recording, interaction-based recording,              curve may dissuade some clinicians from using these de-
duration recording, and interval recording of observed           vices at all. From a psychometric standpoint, the effect
behavior. The software is also capable of several types          collecting data using a handheld device has on client be-
of data analysis (e.g., interobserver agreement, sequen-         havior (e.g., reactivity effects) is not well understood.
tial analysis, duration of events within behavioral              Despite these considerations, however, computer and
states). Similarly, Noldus in 1991 reported the develop-         handheld technology should continue to play an impor-
ment of an early MS-DOS-based coding system called               tant role in the evolution of behavioral assessment.
The Observer, and a subsequent multimedia revision,
that allow researchers to construct complex coding
templates and code behavioral responses as they oc-
                                                                                       IX. SUMMARY
curred. Other computerized observational coding sys-               Behavioral assessment emphasizes the measurement
tems are available to behavioral researchers and have            of variables that are highly specific and require low
been extensively reviewed in the literature.
   Self-monitoring software has also been developed for
handheld devices. An advantage of handheld devices is               3 However, the tools for developing such software are readily
that they promote assessment of momentary states in the          available. For instance, Microsoft offers copies of Embedded Visual
natural environment. Recent research has found that as-          Basic 3.0 free of charge through its Web site. The software allows de-
sessment of momentary states may yield results that are          velopers to create user interfaces for a number of handheld and palm-
significantly different from participant’s retrospective rat-     top devices and debug the software in an emulated mode on a
ings of their behavior and skills. For example, some re-         desktop computer platform. Data saved in an Embedded Visual Basic
                                                                 application can be downloaded to Microsoft Access for analysis. In
searchers have reported that retrospective self-report           order to run Embedded Visual Basic 3.0, users should have the Win-
measures of coping skills were very poor predictors of           dows NT 4.0 or Windows 2000 operating systems installed on their
how well individuals actually cope in stressful situations.      development computers.
182                                                    Behavioral Assessment

levels of inference, over multiple assessment periods,              Farrell, A. D. (1999). Evaluation of the Computerized Assess-
across multiple methods and modes of responding. The                  ment System for Psychotherapy Evaluation and Research
behavioral assessment paradigm is closely tied to be-                 (CASPER) as a measure of treatment effectiveness in an
havioral principles first elucidated almost 100 years                  outpatient clinic. Psychological Assessment, 11, 345–358.
ago. The vitality of behavioral assessment and behavior             Gulley, V., & Northrup, J. (1997). Comprehensive school-based
                                                                      behavioral assessment of the effects of methylphenidate.
therapy is evidenced by the exponential growth of jour-
                                                                      Journal of Applied Behavior Analysis, 30, 627–638.
nals devoted to their study.
                                                                    Handwerk, M. L., Larzelere, R. E., Soper, S. H., & Friman, P.
   The behavioral assessor may choose from a variety                  C. (1999). Parent and child discrepancies in reporting
of assessment methods (e.g., naturalistic behavioral                  severity of problem behaviors in three out-of-home set-
observation, analogue behavioral observation, psy-                    tings. Psychological Assessment, 11, 14–23.
chophysiological measurement, behavioral rating                     Haynes, S. N. (1993). Treatment implications of psychologi-
scales, self-monitoring, behavioral interviews, and                   cal assessment. Psychological Assessment, 5, 251–253.
behavioral questionnaires). The ultimate goal of be-                Haynes, S. N. (2000). Behavioral assessment of adults. In G.
havioral assessment is to facilitate clinician hypothe-               Goldstein & M. Hersen (Eds.), Handbook of psychological
ses about client functioning and develop a clinical                   assessment (pp. 471–502). London: Elsevier Science.
case formulation that will suggest the most effica-                 Haynes, S. N. (2001). Clinical applications of analogue be-
cious treatment intervention. Several behavioral and                  havioral observation: Dimensions of psychometric evalua-
cognitive-behavioral researchers have developed clin-                 tion. Psychological Assessment, 13, 73–85.
ical case formulation models in recent years and the                Haynes, S. N. (2001). Introduction to the special section on
                                                                      clinical applications of analogue behavioral observation.
importance of these models in focusing treatment
                                                                      Psychological Assessment, 13, 3–4.
planning continues to increase. With the develop-
                                                                    Haynes, S. N., Gannon, L. R., Orimoto, L., O’Brien, W. H., &
ment of sophisticated handheld and desktop com-                       Brandt, M. (1991). Psychophysiological assessment of
puter applications that ease data collection and                      poststress recovery. Psychological Assessment: A Journal of
analysis, the family of behavioral assessment meth-                   Consulting and Clinical Psychology, 3, 356–365.
ods should continue to evolve as the most useful way                Haynes, S. N., Leisen, M. B., & Blaine, D. D. (1997). Design
to assess the relationship and importance of variables                of individualized behavioral treatment programs using
operating in a client’s life.                                         functional analytic clinical case models. Psychological As-
                                                                      sessment, 9, 334–348.
                                                                    Haynes, S. N., & O’Brien, W. H. (2000). Principles and prac-
       See Also the Following Articles                                tice of behavioral assessment. New York: Kluwer Acade-
Behavioral Case Formulation I Behavioral Consultation                 mic/Plenum Publishers.
and Therapy I Behavioral Therapy Instructions I                     Haynes, S. N., Richard, D. C. S., & Kubany, E. (1995). Con-
Documentation I Functional Analysis of Behavior I                     tent validity in psychological assessment: A functional ap-
Neuropsychological Assessment I Objective Assessment                  proach to concepts and methods. Psychological Assessment,
                                                                      7, 238–247.
                                                                    Heyman, R. E., Chaudhry, B. R., Treboux, D., Crowell, J., Lord,
                   Further Reading                                    C., Vivian, D., & Watters, E. B. (2001). How much observa-
Blanchard, E. B., Hickling, E. J., Taylor, A. E., Loos, W. R., &      tional data is enough? An empirical test using marital inter-
   Gerardi, R. J. (1994). The psychophysiology of motor ve-           action coding. Behavior Therapy, 32, 107–122.
   hicle accident related posttraumatic stress disorder. Behav-     Heyman, R. E., & Vivian, D. (1993). RMICS: Rapid Marital In-
   ior Therapy, 25, 453–467.                                          teraction Coding System: Training Manual For Coders. Un-
Boyce, T. E., & Geller, E. S. (2001). A technology to measure         published manuscript. State University of New York, Stony
   multiple driving behaviors without self-report or participant      Brook.
   reactivity. Journal of Applied Behavior Analysis, 34, 39–55.     Korotitsch, W. J., & Nelson-Gray, R. O. (1999). An overview
Carr, E. G., Langdon, N. A., & Yarbrough, S. C. (1999). Hy-           of self-monitoring in assessment and treatment. Psycholog-
   pothesis-based intervention for severe problem behavior.           ical Assessment, 11, 415–425.
   In A. C. Repp & R. H. Horner (Eds.), Functional analysis of                   .                 .
                                                                    McGlynn, F D., & Rose, M. P (1998). Assessment of anxiety
   problem behavior: From effective assessment to effective sup-      and fear. In A. S. Bellack & M. Hersen (Eds.), Behavioral
   port (pp. 9–31). Belmont, CA: Wadsworth.                           assessment: A practical handbook (4th ed., pp. 179–209).
Cepeda-Benito, A., Gleaves, D. H., Williams, T. L., & Erath, S.       Boston, MA: Allyn & Bacon.
   A. (2000). The development and validation of the State           Mowrer, O. H. (1947). On the dual nature of learning: A rein-
   and Trait Food-Cravin